Volume 44 Number 3 | September 2016
Helping to deal with racism as a therapist - Page 14
Volume 44 Number 3 September 2016 Managing Editor Peter Elliott
Contributors Gail Beacham, Andrew Beck, Matt Bristow, Ashley Cave, Elaine Davies, Mike Ellen, Maggie Fookes, Anna Hutchinson, Hannah Waters 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. Submission guidelines Unsolicited articles should be emailed as Word attachments to editorial@babcp.com. Publication cannot be guaranteed. An unsolicited article should be approximately 500 words written in magazine (not academic journal) style. Longer articles will be accepted by prior agreement only. In the first instance, potential contributors are advised to send a brief outline of the proposed article for a decision in principle. The Editors reserve the right to edit any article submitted, including where copyright is owned by a third party. 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 7 November 2016 (for distribution week commencing 9 December 2016) Advertising For enquiries about advertising in CBT Today, please email advertising@babcp.com. Š Copyright 2016 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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Inside 4
Queering CBT
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Low values?
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Excellence awards
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Supporting university wellbeing services
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Is Wales any closer to an IAPT scheme?
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Experiencing racism
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Practicing what we preach
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Sunday roast and therapy
Matt Bristow reports on challenging assumptions
A response to our report in the April issue on Low Intensity therapy in today's busy society
This year's awards from the Annual Conference
Helping under-pressure university support services
A look at the efforts being made to deliver mental health services in Wales
Research findings and discussion about helping service users from the BME community
A therapist talks of dealing with anxiety during a personal illness
Elaine Davies reflects on her CBT practice
ALSO IN THIS ISSUE: 10 Jolly good Fellows 17 Branch and Special Interest Group updates 20 Charlie Waller Memorial Trust receives volunteer award
www.parliamentlive.tv
President’s message Problems of low mood and depression, anxiety and also musculoskeletal problems together make up three common causes of being off work in the long term. There has been debate around why, whether and how mental health screening and intervention can be delivered within Job centres. For example there have been suggestions that IAPT workers be based in job centres to provide support. Although this idea seems at first sight a good one - closer inspection reveals a wide range of potential pitfalls. BABCP has been involved in the Future of Jobcentre Plus Inquiry, and has created various joint responses for this with other key psychotherapy organisations; British Association for Counselling and Psychotherapy (BACP), British Psychoanalytic Council (BPC), British Psychological Society (BPS) and the UK Council for Psychotherapy (UKCP). Our main points are that the idea of detection and supporting people with depression and anxiety could potentially be helpful. How this is done could prove very difficult. We have also been keen to make the point that work is not a health outcome in itself.
There are more issues also. For example by work do we mean meaningful and engaging work - or any work at all? I was also asked to represent the different organisations at the Work and Pensions Select Committee. That committee takes evidence and makes recommendations around these proposals. The main point I tried to communicate was the need to properly pilot the approach before any wider roll out. This would allow pitfalls to be anticipated, identified and hopefully addressed. We have also invited representatives from the Mental Wealth Foundation which represents various interested groups including user groups to attend a future Board meeting so we can hear more fully their concerns about these proposals. The Board is always happy to hear the different views of those in the organisation- so please do let us know your thoughts! Thank you.
The key issues are: - Who will identify anxiety or depression? What would their training be?
Chris Williams BABCP President
- Would this information be provided voluntarily - there must be no coercion. - How would clinical confidentiality be maintained if therapists were collocated in job centres? - Are appropriate quiet and sound proofed rooms available for private discussion of such personal information.
The Work and Pensions Select Committee meeting which Chris Williams attended is available to view at the following link http://tinyurl.com/gspkrpm
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CBT Today | September 2016 3
Queering CBT We were delighted to have been invited to deliver a workshop at this year’s BABCP Spring Conference. We had the chance to work with a fantastic group of professionals discussing diversity in sexuality and gender identity and how CBT might be used in counteracting some of the effects of discrimination, stigma and oppression. Trans issues have been receiving increasing attention in recent years in many countries - for example, in 2014 Time magazine declared the US to be at “the transgender tipping point”, which it described as “America’s next civil rights frontier”. However, as the word frontier suggests, there is still much to be done. That applies equally to this side of the Atlantic too. A recent report by the parliamentary Women and Equalities Committee found that the NHS is failing in its legal duties towards trans people under the Equality Act 2010 and the report highlighted how trans people often face significant difficulties in accessing general NHS services.
Matt Bristow, Anna Hutchinson and Hannah Waters are clinical psychologists and talk about their work at the Gender Identity Development Service, within the Tavistock and Portman NHS Foundation Trust.
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There are of course going to be transphobic attitudes in any large organisation. We should also not forget the sometimes-troubled history mental health professions have had with LGBT people over the years. However, in our experience as psychologists working in a specialist gender identity service for children and adolescents, it is much more common for clinicians nowadays to be keen to help trans clients but they worry that they lack the right skills and knowledge. A dose of the understandable fear of ‘getting it wrong’ is probably quite a
healthy position to be in as professionals. However, when these worries grow and then result in trans people not receiving the same access to local mental health services as others, we need to think collectively about how to challenge some of our own assumptions around working with this part of our society. We would certainly agree that we all need to be doing more to learn how we can ‘get it right’ for trans people accessing services - whether this is through CPD events, informal study, or through contact with trans or LGBT organisations, such as Gendered Intelligence. However, our personal highlight of the recent workshop was seeing fellow clinicians make connections with their existing knowledge and skills and hearing how they would work with both trans and LGB clients to overcome particular difficulties in their lives. We look forward to seeing CBT therapists and practitioners continue to build not only in knowledge but also in confidence in their work with trans and non-binary people and are grateful for the opportunity to be part of this ongoing conversation.
The parliamentary Transgender Equality enquiry findings can be read online at http://bit.ly/1fz9b6t You can read more about Gendered Intelligence at www.genderedintelligence.co.uk
www.babcpconference.com
BABCP Annual Conference 2017 25 – 28 July Manchester
Call for papers Submissions for Full-day Pre Conference Workshops, Symposia, Panel Debates, Clinical Skills Classes are open now Closing date - 6 January 2017 Open Paper and Poster submissions are also welcome Closing date - 1 March 2017
Membership subscriptions 2016/17 The Board is pleased to have agreed to keep 2016/17 membership subscriptions the same as 2015/16 rates. They are also pleased to announce two new categories of membership -
Associate Member, and Student Member.
Student membership is for students in full-time education.
Associate membership is for those who are not currently practising CBT in a professional capacity, while
Both new membership categories will enjoy the full benefits of BABCP membership.
Annual Payment UK & Ireland
Overseas
Ordinary Member (Paid by Direct Debit)
£73.50
£81.50
Ordinary Member (Paid by Cheque/Card)
£81.50
£89.50
Ordinary Member Reduced Rate* (Paid by Direct Debit)
£43.50
£51.50
Ordinary Member Reduced Rate* (Paid by Cheque/Card)
£51.50
£59.50
Associate Member** (Subscription by Direct Debit)
£20.00
£28.00
Associate Member** (Subscription by Cheque/Card)
£28.00
£36.00
Student Member*** (Subscription by Direct Debit)
£25.00
£33.00
Student Member*** (Subscription by Cheque/Card)
£33.00
£41.00
*** The reduced rate is available to those Members who can demonstrate that they have a gross income of less than £21,692 per annum. *** Associate Membership is aimed at those not practising CBT in a professional capacity *** Student Membership is aimed at those attending Higher Education in a full-time capacity
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Low values? Within IAPT services there is forever pressure to meet targets and one of the levels of service that seems to be struggling is the High Intensity service, with not enough staff to cope with the increasing waiting lists.
Following Wasseem El Sarraj’s article in the April 2016 issue of CBT Today about the value placed on Low Intensity CBT, Mike Ellen of Mind in West Sussex adds his own thoughts on work in this area.
Whilst the stepped structure is a sound ideal, the strict boundaries in effect can be limiting in that patients who do not meet the rather narrow criteria for Step 2 really only have Step 3 as an option or maybe opt out of IAPT in favour of private therapy. So is there a case to answer that the relatively limited interventions of Step 2 can be added to with a few ‘minor’ changes so that more patients can be treated at this level? At Mind in West Essex (until May 2015) we held the IAPT contract for five years and used a different therapy model to the IAPT stepped care model. We still had two ‘steps’ but each step had a wider remit. Our ‘Step 3’ was staffed by counsellors (around a hundred) who worked in a wide range of modalities including CBT. Our ‘Step 2’ service was based on the PWP model and used the same assessment, support session protocols and interventions plus Living Life to the Full cCBT programme. As time passed by we discovered that there were some patients who were suitable for Low Intensity support but were struggling to recover as hoped due to the limited PWP interventions available. Some patients were able to use cognitive restructuring as a means of questioning, challenging and reframing negative thoughts, but overall were still seeing little change in how they felt. This applied particularly to patients who had difficulty in changing their situations such as long-term health problems, unemployment or relationship issues (their presenting problems commonly being anxiety and/or depression within Minimum Data Set values for Step 2).
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This left patients and Low Intensity staff frustrated as some progress had been made but all felt that more could be done… but how? My colleagues and I attended an ACT workshop by Russ Harris and this opened doors in adding to our ‘toolbox’. We found that some of the principles and interventions of ACT fitted well with CBT in that, yes, we still started with CBT interventions, principally cognitive restructuring and behavioural activation where appropriate, but when these did not have the hoped for success, using ACT methods often proved beneficial. Helping patients to allow themselves to accept their situations and engage with activities that fulfilled their values often worked well. By bringing in acceptance we found that patients were able to alter their thinking more easily as they could focus more on the present and have hope for the future rather than getting ‘bogged down’ by the negative thoughts linked to the past. This also allowed them to ‘let go’ of the trigger situations and they felt more optimistic for change. We have also found that mindfulness activities have been useful, again in conjunction with regular PWP interventions and work well in managing anxiety and overcoming depression. Mindfulness is gaining more popularity, integrating with various CBT modalities (MBCBT/MBSR/MBCT/CFT/DBT) and following a mindfulness workshop we started sharing this with patients. By engaging with breathing exercises and consciously focussing on activities they were doing (even household chores), plus signposting to websites we found that patients were able to make positive changes and so we added mindfulness to our ‘toolbox’. A not uncommon consequence of
cognitive restructuring is that patients sometimes feel uncomfortable challenging negative thoughts as this keeps the thoughts ‘active’ in their minds, something that they want to reduce or avoid and mindfulness gave some patients a more comforting option. An unexpected benefit was that some patients with sleep problems found free downloads from websites helpful in getting off to sleep. We also used some of the distress managing elements from DBT which we found worked well with people experiencing frustration and anger as well as those experiencing panic. The combination of psycho-education about fight/flight/freeze response coupled with DBT elements and also working on ‘urge surfing’ from ACT we found to be a particularly effective combination. The IAPT Step 2 is not in favour of any sort of distraction, rather working on thought challenging, but this is so limiting. Purely thought challenging can also be tiring for patients, constantly focusing on their negative thoughts and we found that this put off some people. Managing mental illness is also about being kind to yourself and the basic Step 2 interventions do not allow this.
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As time passed by we discovered that there were some patients who were suitable for Low Intensity support but were struggling to recover as hoped due to the limited PWP interventions available
So whilst the IAPT Step 2 interventions are a relevant starting point in Low Intensity CBT work, in themselves these interventions are limited in their effectiveness which surely goes against the principal of IAPT. By adding to these interventions with the CBT-related additions from other modalities a far greater number of people can be helped to reach their goals.
We also benefitted from having supervision from a CBT therapist/counsellor (who was also the lead for the IAPT triage service we ran - and still do), who was able to suggest looking at the additional interventions. By using a more flexible service structure, we were not limited to the strict IAPT model and I believe the patients in our area gained from this different approach.
Further benefits come from relapse prevention using the methods mentioned here and from patients being more engaged. For myself and my colleagues, we would never call ourselves ‘trained therapists’ in the other interventions, but as with all good therapists we know that better outcomes are achieved by having an ‘eclectic toolbox’ to dip into.
So yes, there would be a significant change to the IAPT training in developing extra interventions to come from an ‘evidence base’. There would also be some extension to the PWP training time, but looking ahead to the ‘bigger picture’, how much more effective would this make the IAPT Stepped care service with just a few additions?
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As well as these additions to individual therapy we ran psychoeducation courses. Now whilst these are common at Step 2 level, we delivered the excellent Coping With Life courses developed by Bromley Mind for their IAPT service. The advantage of these is the variety, so in addition to the usual anxiety and depression courses we also ran courses for self-esteem, anger, stress, assertiveness and coping with significant loss and change. They are all based on Step 2 CBT psychoeducation and interventions, but the variety allowed us to work with a greater number of patients.
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Excellence Awards The Scientific Committee has announced the winners of the 2016 Annual Conference Excellence Awards. It was a pleasure to review the potential prize winners this year, and to see studies ranging in focus from process identification to improved training and delivery. Our 2016 judges were Professor Carolyn Becker of Trinity University, and Dr Michael Duffy of Queen’s University Belfast. The Open Paper and poster prizes are awarded to early career researchers and clinicians. Our winning Open Paper presenter was Roberta Bowie, of the Salomons Centre for Applied Psychology, for her study Exposure with and without safety-seeking behaviours in spider phobic students.
inpatient care: a meta-analysis. The winner of the Best Poster award was Katy Sivyer from University of Oxford, with co-authors Rebecca Murphy, Elizabeth Allen, Zafra Cooper and Christopher G Fairburn. Katy’s study, Regular Eating as a Mediator of Enhanced Cognitive Behaviour Therapy for Eating Disorders comprised a mediation study embedded within a large randomised controlled trial, and was funded by the Wellcome Trust. Although regular eating was identified as a possible mediator of treatment efficacy, demonstrating temporal sequence was highlighted as a key target for future research. Judges commented on both the strength of the study design and the excellent presentation.
potentially very tricky clinical scenario, the challenge of treating during major medical testing. The intervention and results were presented in a way that makes it possible for an interested reader or delegate to evaluate or replicate the approach, which was clearly and concisely linked to formulation and cognitive behavioural theory. Shortlisted: Dr Anna Smith with Dr Patrick Davey Virtual Reality in Emetophobia Treatment: A Single Case Experimental Design Lizzie Hodgson with Dr Laura Pass, Dr Hannah Witney and Professor Shirley Reynolds - Brief BA for depressed adolescents delivered by a nonspecialist clinician: A case illustration
Shortlisted: Roberta and her co-authors - Fergal Jones and Blake Stobie - carried out a well-controlled experimental study showing the potential clinical impact of safety behaviours in phobic anxiety. This paper was commended by the judges as:“A solidly designed study addressing an important question, with useful results.”The study demonstrated that completing exposure without safety behaviours was associated with both short and longer term superiority in a behavioural approach task relative to a comparison group which used safety behaviours.
Katy Neal - Validation and psychometric analysis of a novel measure: The Depressive and Obsessive Reassurance Seeking Scale (DORSS) Lisa Keane - Goal Achievement and Low Mood: The role of Mental Imagery and Implementation Intentions
Debra Malkin - Combining the use of prazosin with evidence based psychological approaches for the treatment of nightmares within PTSD.
Anybody can submit a Case Report poster. The number and quality of these submissions seems to be rising year on year and they are a key way of testing and demonstrating clinical innovation and illustrating the application of CBT science ‘in real life’. Our winning author was Nick Stewart, Trainee Clinical Psychologist at the University of Bath, with his report Treatment of health anxiety in parallel with investigations for potentially serious physical illness.
Charlotte Paterson - Effectiveness of psychotherapy in acute mental health
The judges appreciated the way that it addressed an important and
Shortlisted:
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Descriptions of interventions and use of data are two areas that have really strengthened the empirical value of Case Reports at the BABCP conferences recently – keep it up, everyone! Don’t forget to nominate your eligible presentations for consideration – next year it could be you.
Supporting university wellbeing services A recent YouGov report claims that one in four university students lives with mental health problems. Ashley Cave, a PWP and Mental Health Advisor at Sunderland University, tells CBT Today about support provided there for under-pressure university wellbeing services. Often portrayed as the ‘best years of your life’ university can become a pressure cooker for students. Many students are struggling; the stress of living independently and the demands of studies can amplify underlying problems or create new ones. With increased fees comes increased pressure and stress. Universities UK’s mental wellbeing group has published figures that shows an annual increase in demand student counselling services of about 10 per cent, which equates to at least 115,000 students per year seeking support. While universities are getting better at responding to mental health problems, there is still often a strain on university wellbeing resources and a limit in what they can offer. In Sunderland Psychological Wellbeing Services this was something we recognised and were keen to support our local university by building links and offering Step 2 treatments. Initially we arranged a meeting with the head of student
support services and head of counselling at the university. We developed a five week ‘stress-ed’ class for students. This was bespoke to the university but based on our own Step 2 stress class which had been well received by patients in our service. We adapted materials to make it more ‘student friendly’. This included more video clips, interaction and modules on procrastination, time management and managing difficult times such as exam/essay deadlines. This was supportive to the university in managing students who were waiting for counselling but we also opened it up to any students who felt the course would be helpful to them. Our course evaluation highlighted how relevant the class had been for some students: “Although I have completed CBT twice, this stress-ed class has been very helpful as it’s been more related to study. Everything about the classes has been helpful.” “I found it very helpful that we were
Ashley Cave (third from left) along with fellow PWPs graduating from Newcastle University in 2012
given worksheets and techniques, it is exactly what I needed.” As PWP’s we were able to expand our skills to working with a unique group of people including many international students. It was exciting to work on a new project that allowed us to get out into our local community and provide a service to students. As recent graduates, I think this is something we would have really valued - a course on how to manage the pressures that come with being a student and how necessary it is to look after our own wellbeing. The class was also a success in that it allowed us to establish good connections with university staff. This opened the doors for conversations around patient care for students the university refer into IAPT, as well as an increase in referrals from the university for students who require CBT or further support available in IAPT including other group sessions. The university have asked us to have a presence on campus when they run events for World Mental Health Day or wellbeing week. Further discussions have highlighted the potential of running a stress class with an occupational health focus for staff. A survey by the National Union of Students (NUS) in December 2015 found that the majority of students (78 per cent) had experienced mental health issues in the last year, with a third saying they had had suicidal thoughts. While there is still a journey ahead for students to get the right support we were delighted to have the opportunity to have helped some students feel more in confident and in control of their university experience.
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Jolly good Fellows At the BABCP Annual General Meeting held in Belfast, President Chris Williams announced this year’s recipients of the Honorary Fellowship in recognition of distinguished service to the Association and the CBT community as a whole.
Honorary Fellowship Awards Gordon Deakin was awarded a posthumous Honorary Fellowship. As one of the original five Nurse Behaviour Therapists trained by Isaac Marks in 1972, he was very much part of the history of BAB(C)P since the early days of the Association. It is astonishing to look back to 1972 and consider that, as one of the first five people from a nursing background to undertake training in behavioural psychotherapy, quite how controversial a development that was. Gordon was a pivotal figure in the transformation of psychotherapy from an elite, esoteric intervention extending the range of behavioural psychotherapy from our relatively narrow beginnings to the full range of psychological disorders. He had the innate ability to communicate new and, at times, difficult theories and techniques in an understandable, practical and interesting manner.
He continued to teach and do clinical work with a varied caseload until his retirement in 2013. He was a rarity amongst teachers. Not only was he personally inspiring, but he had a very coherent educational philosophy and practice. This meant that his influence on his trainees was an enduring one and there are many in our profession who look back on their contact with Gordon as a pivotal time in their careers. Gordon commanded respect, and was known for honesty, straight talking, and intellectual and moral toughness. He could fight his corner. In a context of professional opposition and declining resource, Gordon kept CBT training alive in Plymouth at a time when opportunities for this training were rare across the country and when political and professional will did not support initiatives to broaden the availability of CBT. Against this background, he not only kept training going, but also made it innovative in both style and content; all with understanding, pragmatism and good humour. The world of CBT is poorer without him, as a teacher and innovator, and the world is infinitely poorer without him as a person.
Dr Michael Duffy
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Professor Judy Hutchings OBE has had a long association with BABCP having become a member 40 years ago this year. Her service to BABCP has been at a local and national level. Judy was one the co-editors of the original BABP Newsletter and also served on the North Wales branch committee for many years. She was a regular contributor BABCP’s workshop and conference programmes and was nominated as the Most Influential UK female CBT researcher/practitioner in the BABCP 30th Anniversary Awards in 2002.
Judy trained as a clinical psychologist in London and Wales and is best known for her work on child behaviour management and parenting. Judy has been influential as a teacher, trainer, researcher, clinician and policy make at a national and international level. Although now retired from the NHS after a long career Judy still works as Director of the Centre for Evidence Based Intervention at Bangor University. Judy’s work has influenced policy both at Westminster and in the Welsh Government and she was awarded an OBE in the Queen’s Birthday Honours in 2010 for the wide contribution that her work with children and families has made. This year BABCP also bestowed Fellowships to the following recipients: Dr Michael Duffy has had a distinguished career in trauma and widely-published research. His work in trauma includes co-leading the farreaching work of the Northern Ireland Centre for Trauma and Transformation. He has provided many workshops on PTSD for BABCP at home and abroad. He is currently Director at the BABCPaccredited MSC in Queens University Belfast. He is also a Senior Cognitive Psychotherapist, specialising in trauma disorders. Professor Jo Smith has a long and distinguished career helping people with psychosis as well as their families, ensuring they receive access to high quality services. She has enjoyed considerable success as Chair of IRIS (Initiative to Reduce the Impact of Psychosis) and as joint-lead of the National Early Intervention in Psychosis (EIP). Her work through EIP is recognised at home and internationally in Australia,
Japan and USA. She still works with clinicians on the front line with the delivery of a wide range of CBT approaches, and it is recognised that her work has helped thousands of people around the world. Dr Mark Serfaty has made significant contributions to CBT in both clinical and academic fields. His research has targeted populations that are often underrepresented in CBT RCTs. His trial of CBT for depression in older adults is the largest published to date. His current research into CBT for depression in patients with advanced cancer is innovative in the way it utilises specialist cancer centre setting of most studies. This trial has had the added bonus of training a large number of CBT therapists in treating this patient group, increasing both their expertise and confidence in dealing with the psychological problems of physical illness. He is an experienced and competent clinician, who combines general psychiatric and CBT skills – a rare mixture in the area. He is skilled in standard CBT, but has also in recent years, developed his expertise in Acceptance and Commitment Therapy. His teaching related to his research work has improved the abilities of therapist to work with older adults, people with learning difficulties as well as cancer patients. Throughout his career, he has demonstrated a commitment to CBT, to expanding its applications and to assessing its efficacy and effectiveness. Satwant Singh’s contribution to the promotion of CBT in the UK is outstanding. His enthusiasm, knowledge, integrity and interpersonal skills make him a significant ambassador for BABCP and CBT in general. He has made a notable contribution to the development of CBT delivery in
Professor Jo Smith receives her Fellowship from BABCP President Chris Williams
primary care, prior to the instigation of the IAPT programme; then leading one of the pilot sites and still working in that setting. He demonstrates exemplary clinical leadership, working in a challenging role, setting high standards and supporting his team to achieve beyond expectations and genuinely improving access to psychological therapies. Whilst maintain a demanding clinical role, he has also been involved in a number of research projects in various areas with a clinical focus. His research in hoarding has helped to advance the field, with original work on both understanding the disorder and improving access to treatments for those experiencing the difficulties. In addition to this, he regularly contributes to training, delivering workshops and teaching in diverse settings, both in the UK and internationally. He continues his own professional development with enthusiasm. He achieves an astonishing level of delivery in clinical areas, while also doing research and teaching, yet, at the same time, giving those he meets the sense that he has time for them and cares personally.
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Is Wales any closer to an IAPT scheme? That was the question on the lips of Maggie Fookes (pictured with John Barber) , a north west Wales-based CBT therapist and Chair of BABCP’s CBT4Wales group, as she went to Cardiff in May 2016 to attend the Mental Health Today conference at the city’s Motorpoint Arena. The conference brought together service users, third sector organisations and statutory bodies with a varied programme of presentations that aimed to examine the current state of mental health services in Wales, particularly in the context of the Welsh Measure 2010, a piece of legislation designed to radically overhaul mental health provision in Wales. The Measure is founded on principles of service user and carer involvement in planning care, holistic integrated and person-centred approaches, effective communication, and equality, dignity and respect for diversity. It sets out rights of patients to assessment, and duties for Health Boards to provide care and treatment plans, the allocation of a care coordinator, regular review, and planned discharge for those patients requiring Secondary Care. The Act envisioned that psychological therapies would form part of the treatments on offer, though it has to be said that the structuring of the legislation in relation to psychological therapies and its positioning in Part Two of the Act has meant there does not seem to have been the same imperative to implement it as there has for the provision of assessment and Care Planning. The Welsh Government has been seeking to redress this imbalance and commissioned an independent review of provision across Wales in 2013 in preparation for the development of a Welsh Matric (Matrix). The conclusions of the review and the proposed Welsh Matric were to be presented at the conference so it seemed important for BABCP to have a presence,
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therefore CBT4Wales booked an exhibition stand. We used this opportunity to promote CBT, membership of BABCP and to network with other organisations interested in improving access to psychological therapies in Wales. I am pleased to report that there was considerable interest. It was quickly apparent that some of the voluntary sector organisations shared some of our concerns about inequalities in the provision of psychological therapies in Wales. Service users stopped to share their experiences of referral for psychological therapies and the delivery of CBT through the NHS in Wales. The main concern was the length of time they had waited, but some had clearly had negative experiences with the way CBT had been delivered reinforcing concerns about training supervision and competencies. Those that described receiving optimal treatment described the experience as ‘life changing’. The concern from therapists who stopped to talk to us had an all too familiar ring, restricted opportunities for Diploma level training in CBT and poor job prospects. The presentation we attended on CAHMS services (Transforming Services for Children and Young People by Welsh Government Mental Health Strategy lead Sian Richards) highlighted high levels of dissatisfaction from service users and carers, especially around waiting times. Encouragingly £7.65million funding has been announced for this all important mental health service. However the focus for change was broad, target driven and barely touched on psychological therapy provision.
So does the Matric offer us all some hope? Well possibly. It will be interesting to see the published version. Clinical psychologist Kim Williams outlined the conclusions from the review of access to and implementation of psychological therapy treatments in Wales. The review had concluded that the Measure had not really delivered all that it intended and that this was at least in part because the strategy was delivered in the context of guidance. Services throughout Wales were described as ‘patchy’ with long waiting lists: an absence of national benchmarking; problems with recruitment and retention of psychological therapists because of a lack of career pathway and training; problems in achieving appropriate initial assessment for psychological therapies because the clinicians carrying out the assessment did not always have the knowledge needed, and the predominance of the ‘medical model’. Service users had reported their impression that they were offered ‘what we’ve got’ rather than what they needed. Without a doubt funding has been an issue. The service changes required by the Measure entailed a considerable extra workload for Health Boards already under pressure from austerity measures and there was no additional funding initially for any of it. Health Boards are stringently monitored on targets for assessment and the completion of care and treatment plans, whilst there has been no requirement for national monitoring of standards or outcomes for psychological therapies. This at least is set to change with the announcement of £1.9million recurring funding to deliver psychological therapies. The allocation of this funding will now be dependent on Health Boards developing plans consistent with the Matrix.
The Matrix for Wales has been modelled on the Scottish Matrix. It is intended that psychological therapies management committees’ accountability to Welsh Government will be strengthened and that services will be delivered adhering to some key national standards. Health Boards will be expected to offer at least one evidence-based treatment and give a choice of one other; treatments should be formulation based to de-medicalise services; national standards of training, supervision and therapist competencies will also be set out more clearly, and training for all clinicians who will be assessing for referral for psychological therapies will also be expected. It is envisaged that accredited training courses will be run in Wales and that practitioners will keep up to date presumably through CPD. It is also expected that Health Boards will continually review and modify treatments to ensure they meet the needs of patients, and to understand why patients don’t engage with treatment. I am left with questions that may only be answered when we see the published Matric. Mainly I am unclear how we will improve on the current situation when the way in which the recommendations are implemented still seems to have been left to individual Health Boards. There may be an incentive to be Matric adherent if funding depends on it, but I wonder what will happen to services in Health Board areas that do not develop an appropriate plan
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for the money. I also wonder what safeguards will be in place to ensure that resources for psychological therapies are not diverted to other mental health provision. As psychological therapists in Wales must have core profession registration these resources would include clinical staff who may be asked to assume more general duties to ensure other targets are met. In England and Scotland a clear economic case was made for investment in psychological therapies, and in both nations the need was comprehensively assessed. This included workforce planning to adequately train the number of therapists required, and specified the level of training required at each tier of service. High Intensity therapists were expected to be trained to Diploma level and be accredited with the relevant body e.g. BABCP. It remains to be seen whether planning for IAPT in Wales will consistently follow such principles.
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Services throughout Wales were described as ‘patchy’ with long waiting lists: an absence of national benchmarking; problems with recruitment and retention of psychological therapists because of a lack of career pathway and training
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Talking to Black and Ethnic Minority service users about their experience of racism
Recent research from the University of Manchester has shown that the more someone from a Black and Minority Ethnic (BME) background experiences racism the more likely they are to develop mental health problems. Consultant clinical psychologist Andrew Beck writes for CBT Today about this issue.
There is good evidence that people in the UK are experiencing more racial harassment since the beginning of the Brexit campaign.
tend to avoid things that make us anxious so it is understandable that we sometimes avoid conversations that we are worried about.
What this means for cognitive behaviour therapists working with BME service users is that there is a good chance that patients have experienced racism over their lifetime and that this might be linked to the onset of their mental health problems or a recent worsening of symptoms.
It is also likely that therapists using manualised approaches to CBT based on the core models that are the foundation of our therapeutic approaches would not think to ask about the wider context of racism and discrimination. This is because these models make little or no reference to the social contexts of service users and their experiences of discrimination as predisposing, precipitating or maintaining factors.
This experience of racism can take many forms including overt violent attacks, verbal abuse or what is now called micro-aggression, which is a term used to describe the small everyday experiences of being treated as being in some way inferior due to someone's ethnic or religious background. Service users are also likely to have experienced racism that has impacted on their life chances and access to jobs, housing, education and other opportunities. Service users from a wide variety of cultures and faiths experience these forms of direct and indirect discrimination including people of South Asian, White European, Jewish and Black African, Caribbean and British backgrounds. We know from past research that many white therapists find it difficult to ask service users about their ethnic background and to begin to think about culture and context either as part of getting to know the lives of the people we are working with or as information that might help in gaining an understanding of the presenting problem. One of the most common reasons that therapists give for this is being worried about getting this discussion wrong and giving the service user the impression that they are racist or culturally uninformed. Therapists are only human and like anyone else we
14 CBT Today | September 2016
What service users say very clearly is that not only do they want to be asked about their ethnic background but that when therapists do so it can strengthen the therapeutic relationship and go a long way towards giving them confidence that a white therapist can understand the social contexts of the problems they are bringing to therapy. Without this initial discussion about ethnic background it would be impossible for therapists to ask about historical and recent experiences of racism as part of understanding the problems that have brought service users to therapy. So with this in mind it seems useful to summarise some key points from what little research has been written on this topic so that cognitive behaviour therapists can feel confident about raising this issue with service users and incorporating this information into formulations and treatment. Firstly therapists need to ask about the culture and background of service users. This is not something that should be done before some degree of therapeutic relationship and trust has been established. Once the core therapy skills of warmth and positive regard have been used to
establish the basis for a working relationship the therapist can begin to look for opportunities to ask about culture, ethnicity and context. Service users are fairly consistent in saying that acknowledging a difference between the ethnicity of the therapist and service user helps this discussion. Service users will often give the therapist cues and openings for these discussions. This might include mentions of their wider family, how they have spent the time since their last appointment (for example mentioning that they spent one day of the weekend at a family function or religious event) or communicating something as simple as having eaten a particular food that can be seen as an element of their cultural life. Therapists might take these cues as an opportunity to say something a simple as 'Could you tell me a little bit more about your family background?'. This provides the service user with an opportunity to say as much or as little as they are comfortable with saying at that moment in time. Dr Ayesha Gurpinal-Morgan, a clinical psychologist at Salford Royal Hospital, carried out research – during which I was lucky enough to be the service supervisor for this work – which found service users were clear that when these cues were not provided it was still important for the therapist to ask about culture and context. One very helpful way into these sort of discussions is to say something like 'It would be really helpful for me to know a little bit more about who is at home. Could we sketch out a family tree?'. Developing a genogram with service users then provides a good opportunity for further discussions about family life, culture and context which can add considerably to a CBT formulation. Co-developing a genogram gives an opportunity to ask about a wide
range of factors to do with someone's background including migration histories in the family, acculturation, languages spoken at home and the importance of different family members in the life of the service user. These kind of discussions can take place over several appointments and as a bond of trust is developed and strengthened more in depth discussions can take place. A good rule of thumb though is to only ask for as much detail as you need to in order to understand the life of the service user enough to help them overcome the problems they have come to therapy with. It can be tempting to use therapy time to learn about an interesting new culture and become educated about a world that might seem otherwise inaccessible but service users aren't coming to therapy for our benefit so some care should be taken about how much is explored. It is also worth remembering that many service users from Muslim faith backgrounds will be very aware of programmes within mental health services to identify service users at risk of radicalisation and to refer them to counter-terrorism programmes. An awareness of this agenda in health services might make Muslim service users wary of the motives of mental health professionals in asking about their faith and religious observance at least until therapists have communicated an understanding of and respect for their faith and background. Once discussions about background and ethnicity have taken place it is likely that enough trust and regard will have been built up for questions about racism to be asked. This could potentially be an uncomfortable experience for both the therapist and the service user. Therapists may well be anxious about asking this question
and feel shame or guilt when a service user describes racist experiences. This does not mean that the therapist is not a good one, it is a very human response to what can be awful stories of discrimination. How you respond to these feelings in session is very much a matter of personal preference. Saying something like 'Just hearing about that makes me feel awful for you and what you have experienced' can communicate something important about your reactions to hearing about difficult situation. Acknowledging that as a white therapist it is difficult to hear about the way someone from your own community has acted can also be helpful for some service users. Other therapists might find it works better for them and the service user to remain engaged and encouraging but not say anything directly about how that makes them feel. However we choose to respond supervision can be a very useful place to reflect on what this process was like and think about how we might want to respond next time. There is no one right time or right way to ask about experiences of racism. Again service users might give cues or speak about these kind of experiences without prompting from the therapist, particularly if discussions about culture and ethnicity have given the message that you are a therapist who is comfortable and skilled around discussion of these topics. A direct question can be very helpful when no cues have been given. This might be done as simply as saying something like 'I am wondering what it was like to be from one of the few black families in your Continued overleaf CBT Today | September 2016 15
Talking to Black and Ethnic Minority service users about their experience of racism Continued area?' or when someone is describing a difficult situation such as being bullied at school or marginalised at work a question like 'Do you think being from a minority group had any part to play in what happened?'. One question that I have found very helpful is to ask if it is okay to ask about experiences of racism. This question can be phrased like 'I am wondering if it is okay for me to ask about whether you experienced racism in that situation?' gives service users to an opportunity to say yes or no to further questioning in that area. Since the European Union referendum I have found BME service users mentioning the outcome of this vote in therapy and this can be a cue to say 'I wonder if you have noticed being treated differently since the campaign started?'. This has led to some service users discussing incidents of abuse and it is striking that for some this has been the first time in years that this has happened to them. People have reported a changed sense of belonging and safety as a result of these or incidents like this happening to people they are close to. Once the discussion has begun there are many ways that this information can be used in therapy. Collaborative formulations give therapists the opportunity to ask service users about how this information can be used to gain a better understanding of their problems. Experiences of racism may be a predisposing or precipitating factor for mental health problems and bringing this information into this
16 CBT Today | September 2016
part of the formulation can give a sense of jointly understanding the wider societal context for someone developing mental health problems. This information can also be used to understand maintaining factors. For example a BME service user with social anxiety who is experiencing ongoing racism may talk about thoughts about being negatively judged by others on the basis of their ethnic background. Therapists and service users then have the challenge of thinking about the lived reality of the service user where the context for them includes recent racist experiences and the degree to which they have realistically appraised how much risk of racist abuse, attacks or negative judgement is in their environment and the possibility that part of the presenting problem is that they have overgeneralised from the fact that some white people are racist to thinking that most or all are and that they are highly vulnerable as a result. Care should be taken when exploring these ideas not to minimise or discount experiences of or concerns about racism in any way. Hearing about racism in such an intimate way is uncomfortable and therapists might be tempted to downplay experiences so as not to challenge their own beliefs that society is essentially fair and reasonable. Listening to these stories and helping service users understand their problems in the context of these can
be an empowering experience for them and it might be that part of their recovery process involves politicising their experiences and working towards challenging racism at a wider level in society. This is just a short introduction to a large topic and I would encourage therapists interested in this area to meet with others with similar concerns, to look at the research in this area, to raise the issue in their teams and join the dialogue in the BABCP and the Equality and Culture SIG about this important topic. I have written this from the perspective of a white therapist and I think there is a very good article to be written from the point of view of BME therapists hearing this information as it is likely that some of the issues will be very different.
Dr Andrew Beck is Chair of the BABCP Equality and Culture SIG and author of Transcultural Cognitive Behaviour Therapy for Anxiety and Depression: A Practical Guide. Routledge (2016). He is Consultant Clinical psychologist in East Lancashire CAMHS, Honorary Senior Lecturer at the University of Manchester and senior tutor on the Salford Cognitive Therapy Training IAPT course. He also runs workshops on working across cultures with BABCP and in early 2017 will be running a one day workshop on working with anxiety disorders across cultures with the Oxford Cognitive Therapy Centre.
Branch and Special Interest Group updates Following another successful Branch Liaison Committee meeting in Manchester in May, it is perhaps time to provide readers with an update on the current Branches and Special Interest Groups (SIGs).
Branch and Special Interest Group email contacts
The latest Branch to launch is the Liverpool Branch. Members in the city and surrounding areas will now receive updates on CPD events and workshops held in the city. Watch out for details of the Branch’s first meeting.
Branches
This follows the hard work carried out by members in South East Wales to get their Branch off the ground. They held a very successful inaugural event in Cardiff in July, with Professor David Clark their guest speaker.
Devon & Cornwall . . . . . . . .devon-cornwall@babcp.com
One of the highlights of the Branch and SIG year is the award for Branch Excellence, presented at our Annual General Meeting. The 2016 Neil Harmer Award went to the Irish Association for Behavioural & Cognitive Psychotherapies (Above) IABCP Chair Paddy (IABCP), in recognition Love receives this year’s Neil for the work carried out Harmer Award from BABCP by Branch members in President Chris Williams ensuring a very successful Annual Conference held in Belfast in June. IABCP Chair Paddy Love (pictured left) is stepping down at the Branch AGM in October after six years at the helm.
Ireland . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iabcp@babcp.com
After hosting the 2016 Annual Conference in Belfast, the IABCP are hosting a conference in Dublin in March 2017 entitled ‘CBT in Ireland’. This conference is aimed at bringing together all stakeholders across all Ireland. Full details will be available in the December issue of CBT Today.
Chester Wirral & North East Wales . . . . . . . . . . . . . . . . .chester@babcp.com East Midlands . . . . . . . . . . . . .east-midlands@babcp.com Eastern Counties . . . . . . . .eastern-counties@babcp.com Glasgow . . . . . . . . . . . . . . . . . . . . . . . .glasgow@babcp.com London . . . . . . . . . . . . . . . . . . . . . . . . . .london@babcp.com Manchester . . . . . . . . . . . . . . . . . .manchester@babcp.com North East & Cumbria . . . . . . . .ne-cumbria@babcp.com North West Wales . . . . . . . . . . . . . .nw-wales@babcp.com Scotland . . . . . . . . . . . . . . . . . . . . . . . .scotland@babcp.com South East . . . . . . . . . . . . . . . . . . . .south-east@babcp.com Southern . . . . . . . . . . . . . . . . . . . . . . .southern@babcp.com South East Wales . . . . . . . . . . . . . . . .se-wales@babcp.com South West Wales . . . . . . . . . . . . . .sw-wales@babcp.com West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .west@babcp.com West Midlands . . . . . . . . . . . .west-midlands@babcp.com West Yorkshire . . . . . . . . . . . . . . . .west-yorks@babcp.com Yorkshire . . . . . . . . . . . . . . . . . . . . . . .yorkshire@babcp.com Special Interest Groups Acceptance and Commitment Therapy . . . . . . . . . . . . .act-sig@babcp.com Children Adolescents &
Branches across Wales, brought together under the CBT4Wales banner, had representatives at the Mental Health Today conference, held in Cardiff earlier this year. Details of this are elsewhere in this issue. Thanks must go to all our volunteer committee members for their dedication to providing high-quality CPD events throughout the year. All Branch and SIG events are advertised in each issue of CBT Today. Full information for each event is on the BABCP website, with registrations accepted at workshops@babcp.com.
Families . . . . . . . . . . . . . . . . . . . . . . . . . . .caf-sig@babcp.com CBASP . . . . . . . . . . . . . . . . . . . . . . . . . . . . .cbasp@babcp.com Compassion . . . . . . . . . . . . .compassion-sig@babcp.com Control Theory . . . . . . . . . . . . . . . .control-sig@babcp.com Couples . . . . . . . . . . . . . . . . . . . . . . . . .couples@babcp.com Dialectical Behaviour Therapy . . . . .dbt-sig@babcp.com Equality & Culture . . . . . . . . . . . .equality-sig@babcp.com Independent Practitioners . . . . . . . . . .ipsig@babcp.com IT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .it-sig@babcp.com Medics . . . . . . . . . . . . . . . . . . . . . . .medics-sig@babcp.com Supervision . . . . . . . . . . . . . .supervision-sig@babcp.com
CBT Today | September 2016 17
The power of practicing what we preach Gail Beacham works in a Primary Mental Health Team in Enniskillen, and writes of her own experience of dealing with anxiety during her journey living with cancer.
(Above) Gail Beacham enjoying the support of her dog Jack
I work with clients experiencing a range of distressing and debilitating anxiety and depression related issues. Concerns over long CBT waiting lists due to a shortage of therapists prompted me, when the opportunity arose to train as a CBT therapist at Queen’s University Belfast. I qualified in 2014 and was fortunate enough to be able to practice as a CBT therapist with excellent support from my supervisor Susan McGandy. In April 2015 I was diagnosed with breast cancer. I suddenly experienced fear and anxiety of an intensity that I never before imagined was possible. The knowledge of the challenging treatment I would have to face together with a totally uncertain future, through my mind into turmoil and my body responded with all the physical symptoms of anxiety. I was unable to settle, sleep or eat. I suddenly became wholly aware of the exertions I had expected clients to embrace when asking them to face their most challenging of fears during treatment sessions. Over the initial few weeks my anxiety intensified, however I was extremely lucky. My husband, who had proof read all my recent CBT assignments which left him with a good understanding of the concepts of CBT, reminded me to practice what I had been preaching to my clients. “Why have you stopped your
18 CBT Today | September 2016
Mindfulness practice?” he asked, adding:“You need to use these things now”. That was a turning point and I slowly began to reread CBT and Mindfulness literature. I began by downloading The Body Scan meditation to my phone. I practiced this at night and with practice it helped relax me and assist me to sleep. I was also able to have this resource with me at all times during hospital admissions and waiting for chemotherapy treatments. I found the guided meditations beneficial to focus my wandering mind. During chemotherapy treatment which had resulted in problematic sickness and a multitude of grim side effects, I experienced severe anxiety and episodes of panic. Luckily, due to my CBT training I had an understanding of anxiety and how the human brain works to process threats. I was able to normalise this experience and understand it for what it was, my body trying to protect me. Never the less it was challenging and gave me new insight into the difficulties my clients face. My most passionate interest during my career was the work of Paul Gilbert and his compassion-focused approach to depression. I had also recently bought Deborah Lee’s excellent book The Compassionate
Mind Guide to Recovering from Trauma and PTSD. Through their work I was aware of the importance of being able to ‘self sooth’ and manage my critical self-talk. Being aware of my negative automatic thoughts and self-talk was also helpful when it came to losing my hair and facing people either bald or wearing a wig. I feared people’s reactions and began avoiding going out. As a result, when I had to go out my anxiety was high and I employed numerous safety behaviours. I was reminded by my husband to “straighten my posture” and “make eye contact” with people. To my surprise, every one treated me the same as always. I also remained in situations long enough for my anxiety reduce. I set myself SMART goals and found this, as well as eating well, exercise and structure to my day a helpful way to reduce fatigue. Being aware of what maintains anxiety and depression was helpful throughout the course of my
treatment. I was able to put in place strategies to reduce my isolation. I was honest about my feelings and my fears. My negative self-talk had told me that people would judge me as weak or find me disgusting because of my baldness and other chemotherapy side effects. I decided to treat being open as a behavioural experiment and to my surprise people began to share their fears and difficulties with me. This made me aware that we all have to survive the challenges of life and that others have the same thoughts and emotions. It gave me a sense of perspective about my own difficulties. This was further re enforced when I joined an excellent CBT group run by The Belfast Friends of Cancer Centre. Attending a group as a client was an invaluable experience as we learned about anxiety and the effects of distorted thinking. The peer support gradually reduced our fears, normalised our experiences made us aware that others thought of us as individuals with something to offer rather than
scared and weakened by illness. During these difficult times I held on to wanting something positive to come out of such an arduous experience. I am aware of how lucky I was to have had good resources and the knowledge and understanding to try to manage the inevitable anxiety and low mood. I firmly believe that without CBT I may have experienced agoraphobia and depression as a consequence of the trauma of cancer. I believe this learning, together with the wonderful example set by Northern Ireland Cancer Services for treatment and compassion helped me to recover. One year on and I have returned to work with renewed insight and motivation to continue learning and working with clients. It proved to me without doubt that CBT works, and as practitioners it is vital that we embrace challenges of life with curiosity and as valuable opportunities to practice the skills we have learned on ourselves.
High quality training, supervision and therapy in Acceptance & Commitment Therapy and Contextual Cognitive Behaviour Therapies
The Six Steps to Flexibility: A Two-Day Introduction to the ACT Matrix Benjamin Schoendorff
Friday 3rd and Saturday 4th of March, 2017, London This workshop is based the six-step approach to doing ACT with the Matrix, a proven, highly useful approach to clinical practice. The workshop is based on the new book, The Essentials Guide to the ACT Matrix. You will be taken through key steps that will help you maximize your potential as an ACT practitioner: • Using a simple, elegant ACT formulation method • The 2 rules and hooks • Self-compassion in action • The power of perspective-taking to get unstuck About the trainer Benji is an true ACT pioneer and sought-after ACT trainer, renowned for his ability to make complex notions easily graspable, his warm sense of humor, and most of all for his ability to transmit effective clinical skills to trainees.
Check out our other upcoming 2016 Workshops! ACT for Physical Health Dr Ray Owen 10-11th October, London ACT for Coaches Joe Oliver & Jon Hill 24th October ACT for Depression and Anxiety Dr Russ Harris 16th and 17th June, 2017 For more information on how to register, go to: www.contextualconsulting.co.uk
CBT Today | September 2016 19
Voluntary Service award for Charlie Waller Memorial Trust A voluntary group which works in the community to provide training and education relating to mental health has been honoured with the Queen’s Award for Voluntary Service, the highest award a voluntary group can receive in the UK. The Charlie Waller Memorial Trust aims to equip young people to look after their mental wellbeing through training and resources. The charity also aims to help people to recognise the signs of depression in themselves and others so they know when to seek help and to ensure expert and evidence-based help is available when needed. It also provides training for GPs and others in primary care and co-founded the Charlie Waller Institute at Reading University. The Trust was one of 193 charities, social enterprises and voluntary groups to receive the prestigious award this year. The number of awards given to groups this year is
slightly higher than last year, showing that the voluntary sector is thriving and full of innovative ideas to tackle community challenges. The Trust was set up in 1997 in memory of Charlie Waller, a young man who took his own life whilst suffering from depression. CWMT raises awareness of depression and fights stigma, provides training to schools, primary care staff and employers and encourages those who may be depressed to seek help. It co-founded a chair in Evidence Based Therapies at Reading University known as the Charlie Waller Institute. Charlie Waller Memorial Trust CEO Clare Stafford said:“We are delighted and honoured that the work of the Trust has been recognised in this way. We rely on our loyal and dedicated volunteers in order to continue our work with schools and universities, employers, GPs and other primary care professionals.”
The Queen’s Award for Voluntary Service is the highest award given to local volunteer groups across the UK to recognise outstanding work in their communities. The awards were created in 2002 to celebrate the Queen’s Golden Jubilee and winners are announced each year on 2 June – the anniversary of the Queen’s Coronation.
Dr Pooky Knightsmith providing a CWMT training session to schoolchildren Information on the CWMT can be found at www.cwmt.org and you can be follow them on Twitter at @CharlieWtrust
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- Todays Special Sunday roast and therapy - it is all about the early stages! Elaine Davies is Clinical Team Manager at the Let’s Talk IAPT Hereford service, part of the 2gether NHS Foundation Trust, and takes the opportunity to reflect on her CBT practice. My parents are in their late seventies. I cannot remember a time when they did not have a Sunday roast dinner. It is tradition, it is the thing to do on a Sunday; prepare the vegetables, cook the roast, eat and enjoy, wash up and clean the cooker! (Perhaps it is only my mother who does this!). My parents totally refuse to eat anything else on a Sunday and often cook up to 12 dinners for the extended family.
structure to the sessions, SMART goals to be achieved, skills and techniques for the right level of thought and for the right diagnosis.
Unlike my parents I can eat a varied menu other than the roast on a Sunday. However, like my parents I am partial to the tradition of CBT and thought I would put a couple of lines together to remind us about the fundamentals of CBT practice. I am keen to know what others think.
The relationship is not fully necessary but has to be sufficient for the client to feel empathy, high regard and no judgements. We are often writing on a clipboard or a white board to educate or give rationale to the problems presented.
I suppose it is the meaning you give to traditions and my parents would argue they stand the test of time. I have been thinking more and more about traditional ways of therapy over the last few months and making mental notes following my therapy with clients. In CBT it is a recognised tradition that we have a structure to therapy, a
“
We know that recognising thoughts, developing behavioural experiments, homework setting and homework completion will all help towards recovery. We know that being at the emotion is at the heart of the work.
We take pride not on the mechanical application of techniques but on the understanding of our clients it is tradition that we educate the client in the early stages of what CBT means.
section, environment/trigger, thoughts, feelings, mood and behaviour. Without these early first stages we are likely to move forward too soon with treatment and implement the wrong technique. Following the vicious cycles we ought to be thinking about helping the client understand the different ways we think. We know that anxious thoughts are different to depressed thoughts and they are both different to happy and excited thoughts. The daily thought record is still a great way to help clients illicit, recognise, understand and come up with an alternative thought. In the early stages of therapy often up to as much as 20 sessions is where the best work gets done at negative automatic thoughts and underlying assumptions. Thought records and vicious cycles are still highly underestimated and underused. They can give us so much detail about the client’s life problems. Don’t move too quickly on from these stages. It is such a simple joy when clients return to therapy saying:“I’ve been mind reading and crystal ball gazing all week”. There is nothing more rewarding than helping a client develop and carry out a behavioural experiment to test the longevity of the rules they live by. I believe the pressure of practice, therapist drift, lack of good supervision or maybe even the context in which we work can be part of these traditions slipping.
Vicious cycles and basic formulations are the best tool of intervention. During these early sessions paying attention to the five parts of the model and helping clients to realise the clear difference between each
”
There is nothing more rewarding than helping a client develop and carry out a behavioural experiment to test the longevity of the rules they live by
CBT Today | September 2016 21
South and West Wales Branch presents www.babcp.com
Behavioural Couple Therapy with Andre Geel
Friday 14 October 2016 Port Talbot About Behavioural Couples Therapy Behavioural Couples Therapy is the only NICE-approved couples therapy for addictions and has an extensive evidence-base to support its effectiveness and utility. It is relatively easy to learn - almost irrespective of the therapists’ previous experience and skill - and has begun to be used beyond alcohol and drug problems into more generic addictions and related problems. It also teaches therapists many broader skills found in generic behavioural couples therapy which can be used beyond addiction problems.
Registration fees BABCP members: £50, Non-members: £60
IAPT High Intensity Practitioner Vacancies in Cumbria First Step is the NHS IAPT service for the whole of Cumbria and covers a number of towns in addition to the Lake District, Eden Valley and parts of the Yorkshire Dales. First Step is a reflective and highly supportive service within which to work and is very popular with GPs and also the wider community. We receive about 12,000 referrals per year and have a high recovery rate. This is a large service (90 clinicians in 6 supportive locality teams) and offers an extremely strong internal training programme with a range of high profile visiting speakers, opportunities to take part in facilitated SelfPractice/Self-Reflection programmes and high quality supervision. All practitioners have their own laptop, webcams for recording sessions and an individualised clinical dashboard. Our aim is to support practitioners to reflect and continue developing - whatever the stage in their career.
There are opportunities to become involved in service development or research. See our webpage for more details of our ongoing research projects at https://www.cumbriapartnership.nhs.uk/our-services/mentalhealth/our-mental-health-services/first-step/first-step-research-programmes We have a number of staff who are retiring, or are about to retire, and we therefore have a number of High Intensity roles at both Band 6 and Band 7 at various locations across the county. 1. We welcome applications from CBT clinicians who have successfully completed an IAPT-approved CBT High Intensity Practitioner training and are either accredited or working towards BABCP accreditation. 2. We would also be keen to receive applications from individuals who have completed a Post Graduate Diploma (or equivalent postgraduate certificate which confers eligibility for BABCP accreditation) in CBT, have a strong understanding of IAPT disorder specific protocols and meet the Minimum Training Standards for BABCP Accreditation. Please see our listings on NHS Jobs (search Cumbria and IAPT). We would welcome full time and part time/flexible working applications. If you are interested in relocating to Cumbria and would like to discuss our current or future vacancies please ring Laura Lockhart (Senior Psychotherapist) or Vicky Rooney (Team Leader) on 0300 123 9122.
22 CBT Today | September 2016
CBT Today | September 2016 23
Couples SIG
Eastern Counties Branch
presents
presents www.babcp.com
Couple Therapy for Depression with Dr Michael Worrell
www.babcp.com
Working with Dissociation with Dr Fiona Kennedy
Friday 30 September 2016 Cambridge
Friday 7 October 2016 London Registration fees BABCP members: £90, Non-members: £110, Student: £75*
Dissociation can be understood as psychological processes which result in the inhibition of normal associations. Disturbances of perception, experience and identity can be formulated as involving these processes. The role of dissociation will be discussed, including PTSD, somatic disorders, depersonalisation, borderline personality disorder, eating disorders and dissociative identity disorder.
Cognitive Behavioural Couple Therapy
The day will focus on the practical application of cognitivebehavioural formulations of dissociation. There will be case studies and participants will be invited to bring and work with their own material.
with Dr Marion Cuddy and Dan Kolubinski
Monday 30 & Tuesday 31 January 2017 London
Registration fees BABCP members: £75, Non-members: £85
Registration fees BABCP members: £90, Non-members: £110, Student: £75*
*Evidence of student status must be provided with registration
To find out more about these workshops, or to register, please visit www.babcp.com/events or email workshops@babcp.com Chester Wirral and North East Wales Branch
North East and Cumbria Branch
presents
presents www.babcp.com
www.babcp.com
Intolerance of Uncertainty: A transdiagnostic concept and its clinical implications with Professor Mark Freeston
Friday 21 & Saturday 22 October 2016 Ellesmere Port Day 1 will cover the fundamentals: What makes a construct transdiagnostic? Does Intolerance of Uncertainty (IU) make the grade? Understanding IU and implications for the treatment of anxiety disorders. Day 2 will concentrate more on the skills base and be more interactive: Beyond anxiety: Where does IU come from? IU and the therapeutic relationship. Potential importance as a broadly transdiagnostic construct across axis I and axis II problems, physical health settings and developmental disorders. Initial ideas of how to work with IU across diverse problems, populations and settings.
Registration fees Day 1 only: BABCP members: £90, Non-members: £100 Day 1 & Day 2: BABCP members: £150, Non-members: £160
24 CBT Today | September 2016
Looking after your therapist self with Anna Chaddock
Friday 11 November 2016 Sunderland This workshop is suitable for all therapists. Using experiential exercises, participants will have the opportunity to assess and formulate where they are in relation to the wellbeing of their therapist self, and to reflect on what we know about good therapist self-care compared with what is actually done in practice.
Registration fees BABCP Member: £50, Non-member: £65
High quality training, supervision and therapy in Acceptance & Commitment Therapy and Contextual Cognitive Behaviour Therapies
Relational Frame Theory (RFT) Made Simple Applying the science of language to therapy Dr Richard Bennett & Dr Joe Oliver
Friday 20th January, 2017, London • Do you use psychological interventions in your work as a therapist, coach, or educator? • Are you interested in talking to your clients more precisely and efficiently? RFT is a powerful, and elegantly simple theory that can make a big difference Check out our other upcoming in terms of the precision, speed and focus of your work. 2016 Workshops! In this workshop you will learn: • About the cutting edge contextual behavioural science account of ACT for Physical Health language and cognition Dr Ray Owen • The ways language changes the function of stimuli and alters human 10-11th October, London behaviour in unhelpful ways ACT for Coaches Joe Oliver & Jon Hill • How to make intentional use of language to increase therapeutic impact 24th October with precision ACT for Depression and Anxiety • How to use the ACT Matrix - an engaging framework for utilising relational Dr Russ Harris frames in session 16th and 17th June, 2017 About the trainers For more information on how to register, Richard and Joe are both clinical psychologists and highly experienced ACT go to: www.contextualconsulting.co.uk practitioners and trainers, working within the NHS and private practice.
CBT Today | September 2016 25
North West Wales Branch
South East Branch
presents
presents www.babcp.com
www.babcp.com
Trauma Focused Cognitive Therapy for PTSD with Dr Nick Grey
Friday 28 October 2016 Bangor This workshop presents the Ehlers and Clark (2000) cognitive model for PTSD and the effective treatment that is derived from it. The treatment focuses in three key areas: addressing the nature of trauma memory; tackling negative appraisals and meanings; and developing more helpful coping strategies, overcoming avoidance. The memoryfocused techniques include reliving/exposure, written narratives, stimulus discrimination and site visits.
Using Imagery in CBT with Tobyn Bell
Wednesday 9 November 2016 Sevenoaks This workshop is suitable for therapists wanting to develop their confidence and skills in working with mental imagery in CBT, and will cover several areas, including conceptualisations of mental imagery and the ‘special relationship’ imagery has with emotion and memory; assessment of mental imagery and its role in psychotherapy; and developing ‘positive’ imagery.
Registration fees BABCP members: £80, Non-members: £90
Participants will have the opportunity to practice and experience evidence-based imagery interventions.
Registration fees BABCP members: £70, Non-members: £80
To find out more about these workshops, or to register, please visit www.babcp.com/events or email workshops@babcp.com Southern Branch
Supervision SIG
presents
presents www.babcp.com
www.babcp.com
Working with Interpersonal Process in CBT Supervision with Dr Stirling Moorey
Wednesday 19 October 2016 Sevenoaks
Working with Resilience with Joy McGuire
Thursday 23 February 2017 Southampton Clients in therapy may have become defeated by depression, anxiety or life events and often lose sight of any strengths or resilience they may have. This workshop, based on Padesky and Mooney’s (2012) Four Step model of strengths-based CBT, will enable participants to gain an understanding of the model and how it can be utilised to build and strengthen personal resilience with clients. Participants will also have an opportunity to explore and practice creative ways to formulate resilience and adapt this to enhance therapy.
Registration fees BABCP members: £90, Non-members: £100, Students: £70
26 CBT Today | September 2016
This workshop aims to give CBT supervisors a model for understanding the interpersonal process of the therapy session and the supervision session. The workshop will describe how cognitive models have been used by theoreticians from psychodynamic (e.g. Bowlby and Horowitz), cognitive behavioural (e.g. Saffran and Segal) and integrative (e.g. Ryle) traditions to understand the therapy relationship.
Registration fees BABCP Member: £65, Non-member: £80
West Midlands Branch
Yorkshire Branch
presents
presents www.babcp.com
CBT for Command Hallucinations with Dr Alan Meaden
Tuesday 18 October 2016 Birmingham This workshop aims to provide attendees with an understanding of the theory and cognitive model of command hallucinations, an overview of the treatment protocol and the opportunity to develop skills in formulation and treatment planning. The workshop is based on the protocol developed for the trial therapists on the recent multi-centre RCT (COMMAND).
www.babcp.com
Getting the most out of Clinical Supervision with Dr Joanna Stace
Friday 21 October 2016 Wakefield This workshop will consider the factors that seem to make supervision most effective, with the intention of helping to make (and keep) supervision an inspiring, satisfying, safe and useful process. It is suitable for all CBT therapists, whether they are supervising or not.
A variety of teaching methods are used including PowerPoint, video and group formulation and discussion.
Registration fees
Registration fees
BABCP members: £15, Non-members: £18
BABCP members: £70, Non-members: £80
To find out more about these workshops, or to register, please visit www.babcp.com/events or email workshops@babcp.com
CBT Today | September 2016 27
28 CBT Today | September 2016