CBT Today Vol 45 No 4 (Dec 2017)

Volume 45 Number 4 • December 2017

Mental health in low and middle income countries Also inside - Harnessing the energy of the Third Wave and beyond

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

contents Main Feature

www.babcp.com

Volume 45 Number 4 December 2017

“

Welcome to the final issue of 2017. Thank you to all our contributors for what I hope readers find to be a magazine which provides a breadth of reading interests.

As you will see, there is plenty going on in the world of CBT, it’s unfortunate that we can’t capture more of it.

I’m particularly pleased that we can feature in this issue the work of the new Low Intensity Special Interest Group, whose committee introduce themselves and their aspirations for the LI workforce.

16 Mental health in low and middle income countries – John Minto suggests a call to action for BABCP, with a response from President, Chris Williams

Features 8

Conversion Therapy

10 Harnessing the energy of the Third Wave and beyond

Thank you for reading, as always, I hope you enjoy the magazine.

13 The ABC of CBT in a nutshell

All the best for the festive season, wishing you a happy and healthy 2018!

14 The importance of data collection, signposting and ‘appropriate’ awareness in working with sexual orientation

Peter Elliott Managing Editor peter.elliott@babcp.com

”

19 So you think you understand behaviour?

20 Health, work and IAPT

Contributors

22 BABCP and me

Sarah Bateup, Tom Brown, Kate Davidson, Elizabeth Forrest, Fiona Kennedy, Allan Laville, Sheena Linness, Lucy Maddox, Farhana Maleque, Warren Mansell, John Minto, Ann O'Hanlon, David Pearson, Chris Williams

24 Calling all those who work with Low Intensity Cognitive Behavioural Therapies!

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.

25 Liverpool Branch look at online CBT provision

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 29 January 2018 (for distribution week commencing 23 February 2018)

Advertising For enquiries about advertising in CBT Today, please email advertising@babcp.com. © Copyright 2017 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 2017

26 IT blog

Also in this issue 4 5 6 7 9

News, tCBT Call for Papers News, Chis Freeman obituary Accreditation update 2018 Annual Conference Call for Papers News, 2018 Spring Conference

welcome

From the President: Professional status or interest group?

We are currently an interest group of practitioners as described in our Articles and Memoranda. A wider discussion has been around for many years concerning whether BABCP should become, or at least describe itself as, a professional body. You may have seen these issues discussed in recent editions of CBT Today.

Over the next few months we will be seeking feedback from our members on this with a survey, discussions at the National Committees Forum and the Branch Liaison Committee as well as at Board.

A recent Board meeting has agreed to create an Options document summarising the main arguments for and against; i) maintaining the status quo; ii) a formal move to become a professional body; and iii) a hybrid approach where we emphasise our role in providing the professional delivery of CBT – pointing to our role in course accreditation, individual accreditation and complaints/disciplinary work.

Whatever route we take a key element is how we communicate this work externally so that our accredited members with and without a core profession can have their training and skills very clearly noted by external organisations, commissioners and members of the public.

External links The external connections between BABCP and other psychotherapy organisations continues to build, with us joining forces on an update to the Memorandum of Understanding about Conversion Therapy, as well as ongoing responses and representations to the DWP. Both issues are highlighted elsewhere in this issue.

Conference At the 2018 AGM in Glasgow we aim to continue with holding it in the middle of the day to make it easier for members to attend. We have asked the Conference committee to site this near the main venues, and to provide extra time so that it doesn’t overlap as much with lunch or the start of the afternoon programme. The last conference was very well-received with 27.5% more attendees than last year and a positive rating of 89% for the conference overall.

Statutory regulation in Ireland and possible changes to health regulation in the UK BABCP will be writing – along with the Irish branch – to offer our help, knowledge and skills in the developing work for statutory regulation of psychotherapy (a formal commitment in Ireland). In the UK, a government consultation exercise closing on 23 January 2018 is seeking feedback on ways health care regulation such as nursing and medicine, as well as other professions can be regulated. You can take part by going to the following link – https://www.gov.uk/government/consultations/ promoting-professionalism-reforming-regulation Low intensity work Membership and Branch Liaison Manager Michelle Livesey has conducted a survey to see how we can best provide support, information, quality training and potentially accreditation for low intensity workers across the UK and Ireland. At the time of writing, results of the survey aren’t available, but they will be released after they have been collated.

IT – website and database Our move to a new database and website continues, and has fallen behind what was planned. I want to thank our staff in the office for helping us through this challenging time of transition. Their help, forbearance and support is very much appreciated.

Thank you to Allan Brownrigg Allan informed us that he unfortunately has to leave his role as a Trustee because he has been accepted onto a Masters programme at the University of Cambridge Business School. Allan has been an active and much respected member of the Board and we will really miss his perspective and wise words. This was a three year post and a nomination form to find a new Trustee is included in this issue of CBT Today.

Chris Williams, BABCP President

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

December 2017

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in brief...

Drop in number of young people treated in non-specialist wards The Mental Welfare Commission for Scotland released a report in October 2017 showing a significant drop in the number of young people with mental illness being treated in non-specialist wards in Scotland for 2016-17.

Over the last two years the number has reduced by around two thirds.

The figures have gone from a high of 207 admissions across Scotland in 2014-15 involving 175 young people, to 71 admissions involving 66 young people in 2016-17. Most of these admissions were to adult wards.

Mental Welfare Commission Executive Director Dr Gary Morrison welcomed the change, saying:“Children and young people under the age of 18 who need hospital treatment for mental illness should, wherever possible, be treated in a specialist unit, designed to care for their age group.

“We have raised concerns in the past when we saw the numbers going to non-specialist, usually adult wards, rising, and last year we were glad to see a reversal of that trend.

“This year we saw a further drop in those figures, with lower admissions in every health board area in Scotland.

“We know that services have been working hard across the country to achieve this change, and we welcome it.”

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December 2017

Call for papers Special issue of tCBT on cultural adaptations of CBT The Cognitive Behaviour Therapist (tCBT) journal is planning a Special Issue on Cultural Adaptions of CBT to be published in late 2018 with articles submitted by the end of February 2018, guest edited by experts in the field, Faramarz Hashempour, Andrew Beck and Lydia Stone.

The issue is to be focused upon cultural adaptations (in the widest sense) of CBT with the overriding aim being to improve our clinical knowledge and procedural skills around how we can best adapt CBT to ensure we can bring maximum benefit to the full range of the populations we serve, whether as BABCP members in the UK and Ireland but also in the wider global context given the readership of tCBT internationally.

This could include any group of individuals where specific sensitivity and adaptation to CBT might be required (examples could include specific BAME populations, LGBT community, looked after children, rural populations, economically disadvantaged groups, refugees), we would be pleased to publish training or supervision articles that would support CBT therapists in achieving cultural competence (e.g. reflecting on and addressing our own cultural biases and how these impact on the CBT we deliver).

Articles must be original, focused upon the cultural adaptation of CBT and provoke reflection on practice with clear clinical and research implications for CBT therapists.

If you are unsure whether a potential contribution might be within the scope of the issue then please contact the journal at cbt.editor@babcp.com for a discussion.

Lydia Stone is a clinical psychologist and CBT psychotherapist who has been using cognitive behaviour therapy with adults, children and families since 2004.

Having worked in primary care, secondary care and specialist trauma services in London, she then became principal clinical psychologist at Mirembe Psychiatric Hospital in Tanzania, where she developed and led CBT training for clinicians across Tanzania. She has published work on crosscultural psychology, including reports on CBT training and brief interventions for psychosis in developing countries. Whilst currently working as principal clinical psychologist in the ATTACH team in Oxford (with adopted and looked after children) she continues to support colleagues in Tanzania through supervision and teaching. She worked with Faramarz Hashempour to launch the BABCP Equality & Culture Special Interest Group and was then Chair for several years before handing over the role to Andrew Beck.

Andrew Beck has worked as a cognitive behaviour therapist since 1997 and has published several research papers on transcultural CBT, including work on clinical outcomes and the views of service users who have benefited from CBT. He is senior lecturer on the North West England IAPT training programme and Honorary Senior Lecturer on the Doctorate in Clinical Psychology at Manchester University. Beck is Chair of the BABCP Equality & Culture Special Interest and has worked with colleagues in Chennai to establish the first stand-alone CBT training course in India. You can follow him on Twitter @andrewbeck45

News

Should mental health education be compulsory in schools?

MPs recently debated whether mental health education ought to be taught in schools as part of the national curriculum.

The debate was triggered after a petition by the Shaw Mind Foundation reached the 100,000 signature threshold required – the first time that a mental health charity has reached that number of signatures on the Government Petition website.

This year, for the first time, every school needs to train at least one teacher in mental health first aid, after £200,000 was provided by the government, but children are not currently required to receive mental health education.

Shaw Mind Foundation founder Adam Shaw said:“It is essential that we improve mental health education in schools to reduce the taboo around conditions such as OCD, anxiety, depression, eating disorders and others.”

“Teachers and schools deserve the support and investment necessary to tackle mental health properly. This can only be achieved if mental health education is compulsory and the government commits to funding it properly. Responsibility should not lie solely with teachers and schools.

They should be supported.”

“So far, mental health education as a small part of personal, social, health and economic education (PSHE) lessons has failed to give adequate weight to the subject, and it is not taught uniformly across the country.”

Professor Christopher L Freeman It is with great sadness that CBT Today has to share the news of the death of Chris Freeman on 20 August 2017, aged 70.

Professor Christopher Freeman was one of the leading psychiatrists of his generation who made a major contribution from his base in Edinburgh throughout Scotland and beyond in training, pioneering services, teaching and research. He was a natural cognitive therapist with an enquiring mind and a tendency to challenge conventional wisdoms.

He made a significant contribution to the development of cognitive behavioural psychotherapy in Scotland. Along with Kate Davidson, Chris was co-founder of the South of Scotland CBT Course, which has provided a comprehensive training in CBT for more than twenty years.

Although Chris had an excellent academic record, he was at heart a clinician determined to deliver high quality evidence-based services to his patients. His contributions across his career were at opposite poles of the therapeutic spectrum – from research in ECT to the application of evidence-based psychotherapies, particularly CBT. In 1987 he founded the Cullen Centre for patients with eating disorders (named after the distinguished 18th Century Scottish physician, William Cullen). This centre pioneered the development of an intensive home treatment team approach for anorexia nervosa thus avoiding hospital admission.

In response to the increasing number of patients with symptoms of post traumatic stress referred to the psychotherapy service, Chris – along with psychologist Claire Fyvie – established the Rivers Centre in 1997. This city centre-based resource treats combat victims and rescue service personnel in addition to victims of everyday civilian trauma. He chaired the UK Trauma Group, a managed clinical network of all the trauma services in the UK, both in the independent sector and in the NHS. Despite his many distinguished and innovative achievements, Chris was self-effacing and modest. He was popular with trainees who valued placements with him and found him both approachable and supportive. He leaves behind a legacy of making a difference to evidence-based treatment for patients and in training staff in CBT. Kate Davidson and Tom Brown

December 2017

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accreditation

Accreditation Reaccreditation update Largely due to the complexities of the new database technical requirements and combining this with the new website, the new Reaccreditation system is still not ready to be launched.

We hope that this will be launched early in 2018.

Members affected will remain accredited during this time, and we recommend that those members continue to follow the guidelines for ongoing supervision and CPD, and use the forms available on the website (CPD and Supervision buttons).

Full updated reaccreditation guidelines will be published when the new process is formally launched.

Completion of this form would activate the member’s inclusion on CBT Register UK, as well as the Register for Accredited Supervisors and/or Trainers (if applicable), which is currently hosted in the Accreditation section of the BABCP website.

The previous charge of £30 for this service has now been incorporated into the main accreditation application, so is no longer paid as a stand-alone fee. The reaccreditation fee has been increased accordingly to include this previously separate payment.

As a result, all accredited members are automatically listed on the CBT Register from the date of their accreditation award.

CBT Register - Forms and Fees Update There have been some changes to accreditation fees which we would like to explain, and to reassure members that there has been no actual increase in the amounts due.

Until recently, after any accreditation, members were required to complete and return an Activation form for the online CBT Register.

This standard listing provides members with their name and town/city so that their accreditation status can be verified by third parties.

Full register listing Practitioners who would like their contact details to be available over and above the standard listing can apply for a ‘Full’ listing on the register. This enhanced listing allows members to provide contact details, as well as listing client groups, languages used, and a link to a website. The cost of this listing is £110 per year, over and above the annual accreditation fee.

An online application system is planned for 2018, when it will be possible to request and pay for a full listing through the new website. Until then, if you would like to have a full listing at any point after your accreditation award, please email babcp@babcp.com.

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December 2017

conference

University of Strathclyde, Glasgow 17-20 July 2018

Call for Papers is now open!

The BABCP Scientific Committee invite you to submit proposals for Full Day Workshops, Symposia, Clinical Skills Classes, Panel Discussions and Roundtable Debates.

The closing date for submissions is 6 January 2018 Go to www.babcpconference.com now to submit Workshop Leaders and Keynote Speakers confirmed so far: Frederike Bannink, Amsterdam Michelle Craske, University of California, Los Angeles Ray di Giuseppe, St John's University, New York Barney Dunn, University of Exeter Anke Ehlers, University of Oxford Andrew Gumley, University of Glasgow Ian James, Northumberland, Tyne and Wear NHS Foundation Trust

Freda McManus, Stirling University Rory O'Connor, University of Glasgow Michaela Swales, Bangor University Hannah Turner, Southern Health NHS Foundation Trust Glenn Waller, University of Sheffield More to be confirmed soon!

Registration will be open soon. For more details on the programme, guidelines on submissions and updates on confirmed speakers, please go to www.babcpconference.com

December 2017

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Leading UK psychological professions and Stonewall unite against

Conversion Therapy BABCP recently came together with other leading therapy organisations as a signatory to the updated Memorandum of Understanding against Conversion Therapy.

This updated Memorandum of Understanding (MoU) against Conversion Therapy makes it clear that conversion therapy in relation to gender identity and sexual orientation (including asexuality) is unethical, potentially harmful and is not supported by evidence.

Conversion therapy is the term for therapy that assumes certain sexual orientations or gender identities are inferior to others, and seeks to change or suppress them on that basis.

The primary purpose of the 2017 MoU is the protection of the public through a commitment to ending the practice of ‘conversion therapy’ in the UK. The 2017 MoU updates one released in 2015 at the Department of Health, which focused exclusively on sexual orientation, and is endorsed by the lesbian, gay, bisexual and transgender charity Stonewall.

The MoU also intends to ensure that: • The public are well informed about the risks of conversion therapy • Healthcare professionals and psychological therapists are aware of the ethical issues relating to conversion therapy • New and existing psychological therapists are appropriately trained

Sexual orientations and gender identities are not mental health disorders, although exclusion, stigma and prejudice may precipitate mental health issues for any person subjected to these abuses. Anyone accessing therapeutic help should be able to do so without fear of judgement or the threat of being pressured to change a fundamental aspect of who they are.

BABCP president Chris Williams says:“BABCP advocates mutual respect, and the right to be valued and accepted for who we are. We oppose coercion or the imposition of unwanted therapies.

As such we strongly support the joint memorandum against conversion therapy.”

The Memorandum of Understanding on Conversion Therapy is signed by: - Association of Christian Counsellors - British Association for Counselling and Psychotherapy (BACP) - British Association of Behavioural and Cognitive Psychotherapies (BABCP) - British Psychoanalytic Council (BPC) - British Psychological Society (BPS) - College of Sex and Relationship Therapists (COSRT) - GLADD (The Association of LGBT Doctors and Dentists) - National Counselling Society - NHS England - NHS Scotland - Pink Therapy - Royal College of General Practitioners - UK Council for Psychotherapy (UKCP)

“

We oppose coercion or the imposition of unwanted therapies. As such we strongly support the joint memorandum against conversion therapy.

”

• Evidence into conversion therapy is kept under regular review • Professionals from across the health, care and psychological professions work together to achieve the above goals.

The Memorandum of Understanding document can be downloaded from http://www.babcp.com/files/Press/Memorandum-of-Understanding-on-Conversion-Therapy-in-the-UK.pdf 8

December 2017

news

Longest-running CBT course celebrates 30 year milestone The Postgraduate Diploma in CBT, part of the Institute of Psychiatry, Psychology and Neuroscience based at Kings College London’s Denmark Hill campus, is celebrating its 30 year anniversary as the longest-running CBT course in the UK. With distinguished alumni including Professor Sir Simon Wessely, Professor Louis Appleby and Professor Elizabeth Kuipers, the course initially developed as a five-month certificate to focus on Beck's Cognitive Therapy for Depression, and as theory and research rapidly increased in subsequent years, it grew to accommodate new developments.

Since becoming a full-time course in 2008 as part of the IAPT initiative it has successfully trained high numbers of the London IAPT workforce, taught by experts in CBT actively involved in CBT practice and research developments.

Dr Stirling Moorey has worked on the course across the 30 years. He said:“In the 30 years since we started, CBT has moved from being a newcomer, suspiciously eyed by pure behaviourists on one side and psychoanalysts on the other, to the mainstream. As it has grown over the years dedication, enthusiasm and commitment of teachers and supervisors has remained as fresh as ever.”

BABCP Spring Conference

King’s College London, 12 & 13 April 2018 12 April - Full Day Workshops

13 April - Conference Keynotes

Mindfulness for Psychosis Paul Chadwick and Pamela Jacobsen, King’s College London

Mindfulness for Psychosis Paul Chadwick, King’s College London

Treating Body Image Problems David Veale, South London and Maudsley NHS Foundation Trust and King’s College London Working With Dissociation in Psychosis Fiona Kennedy, GreenWood Mentors Ltd. Living Well with Bipolar Disorder, Lifespan, Approaches to Assessing and Enhancing Personal Recovery Steve Jones and Liv Tyler, Lancaster University

Perinatal mental health Louise Howard, King’s College London There is more to compulsions than meets the eye Christine Purdon, University of Waterloo, Canada Body Image Problems in all its guises David Veale, South London and Maudsley NHS Foundation Trust and King’s College London

For more information and details on how to register, visit www.babcpconference.com

December 2017

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Fiona Kennedy and David Pearson discuss the rationale for integrating CBT and ‘Third Wave’ therapies, presenting CBT Plus (CBT+), an approach combining CBT, ACT, DBT and CFT, illustrated by using a case study from the self-help book Get Your Life Back: The Most Effective Therapies For a Better You which can also be used as a guide by therapists and helpers.

Harnessing the energy of the Third Wave and beyond Having introduced the acronym NAVIGATES in the September issue of CBT Today, this issue provides readers with a case study which illustrates the CBT+ approach.

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A Case Study: Mandy Presenting problems: Feels she is a failure, hears a voice, has difficulty walking Mandy liked cats, Coronation Street, collecting dolls, beef burgers, puzzle books and bingo. She did not like being confronted, green vegetables, walking and Barbara at the Job Centre. Or her family doctor, who refused to sign her mobility forms. At school, Mandy was bullied. Her mum told her she was useless. Dad was never around. When Mandy tried anything challenging she heard her (dead) mum’s voice telling her she was useless, good for nothing. Mandy was afraid that people would think she was mad. She thought it was not fair that people expected her to have a job. When she thought about job interviews she felt depressed and her walking problems got worse.

Mandy’s kind friend said: “I like Mandy. When my cat was poorly, Mandy came round and told me not to worry. We go down to the social club a couple of times a week, for coffee. Mandy has problems getting about. I don’t really understand it. I help her onto the bus. I feel good when I’m with Mandy, helping her, we have a good time. On Sundays we go to a car boot sale and if anyone can spot a bargain, it’s Mandy”.

Mandy’s success story Mandy’s therapist suggested she recorded times when she had walking problems. Mandy wrote a list of what she really values in life and where she wants her life to go. She wanted somewhere nice to live, to be able to earn some money, to look after her health and to love her cats.

Mandy started noticing that her ability to walk varied: the walking problems happened more when she felt down. She decided to go to the gym.

Her therapist thought that if she could improve her walking at the gym, she could do the same outside.

She made good progress in the gym, in spite of her mum’s voice. But walking outside was much more difficult - her mum’s voice was more powerful.

Her therapist referred her to a voice hearing group.

She learned how normal it is to hear voices. The group suggested she could relate to the voice differently, not letting it bully her around. She learned mindfulness skills. These helped her to focus on what she wanted to, not on what her mum’s voice was saying. Mandy wrote down

feature Core processes N

Name the problem behaviour(s), work towards doing this without judgements

A

be Aware of thoughts, feelings, body sensations and behaviour and of the word around you

V

Values - clarify your values

I

Identify the function of the behaviour and plan to do something different

G

Goals -set some small goals to move towards your values

A

Accept yourself and others, validate and be compassionate

T

Tackle Trauma

E

Emotions and Exposure - learn to identify, experience and regulate emotions

S

Skills training - learn to handle thoughts, urges, flashbacks, images, etc

reasons why she was not a failure. She imagined her mum sitting in a chair. She spoke to her ‘mum’ and stood up for herself, disagreeing with her mum.

A year after that first appointment, Mandy has started a job in the local flower shop and is saving up for a deposit on a new flat.

Using the core processes The therapist in the case study took Mandy through the core processes: NAVIGATES • Name the problem behaviour. Mandy’s fear of being judged and shamed about her internal events (voice hearing) needed to be compassionately, non-judgementally discussed with her. Hearing mum’s voice was not the problem, but Mandy’s response to it – agreeing with the content and giving up. Walking was not a problem but Mandy’s internal experience of fatigue and struggle when walking was. Being as precise as possible in naming the problem and in what contexts it occurs opens up a new way of relating to the experiences involved. The therapist validated Mandy’s fear and feeling stuck.

• Accept the problem behaviour and be aware of thoughts and feelings about it. Mandy was very judgemental about her walking issues, feeling defensive and misunderstood when people tried to talk to her about them. The therapist began to work towards a functional analysis by suggesting that all our behaviours work for us in some way or another, and that she was sure they could find out how the walking problems fitted into the picture.

• Values. Mandy’s life had become restricted through a history of attempting to avoid hearing

her mum’s voice (and therefore life challenges).

Getting clear on what she really valued allowed her to experience a little hope and get the message that she too could have dreams. It changed the direction of the therapy towards getting her life back.

• Identify the function of the behaviour(s). Mandy had always lived within an experiential ‘frame’ of her mother being right. From inside this frame there was no option but to agree with the content of the voice. This gave her a horrible feeling – giving up trying allowed escape from or avoidance of that feeling (negative reinforcement). In response to her context (pressure to get a job), the walking problems were communicating, in a socially acceptable way, her felt inability to function, and helping avoid failing in a public setting (at work). The therapist explained this in simple terms. This opened up the options of finding new ways to deal with the voice and new ways to handle the horrible feelings.

• Goals. Taking ‘baby steps’ towards a goal means developing new competencies. Mandy practicing walking in the gym, with support from the gym staff. This gave her a new social outlet and reversed the ‘contingencies’ operating previously: now walking well was reinforced. There were difficulties generalising this skill to the outside world. Mandy experienced mum’s voice as overpowering in that context.

• Accept yourself and others, validate and be compassionate. Mandy had learned she was worthless and a burden. Self-loathing is a central theme in mental health problems. CompassionContinued overleaf

“

Being as precise as possible in naming the problem and in what contexts it occurs opens up a new way of relating to the experiences involved.

” December 2017 11

Harnessing the energy of the Third Wave and beyond Continued

“

Giving a basic understanding and teaching skills is one way of addressing the massive global shortage of mental health, wellbeing and resilience resources.

”

focused interventions are an effective way of addressing this issue. The two-chair work, answering the ‘bully’ (mum) back, and creating lists of her (Mandy’s) achievements, are examples of compassion focused work. Other work was done on Mandy’s childhood experiences and reframing the events as mum’s problems, rather than the child’s.

‘defusion’ (separating the self from the thought), Socratic questioning and thought reviewing.

Specific skills can be learned to handle internal events such as flashbacks, and distressing body sensations. Skills teaching can be delivered in groups, as in DBT, or tailored to the client and taught individually. Mandy learned mindfulness, ‘thought catching’, and voice-handling skills.

• Tackle Trauma. The consequences of Mandy’s emotional abuse history were tackled through self-acceptance and validation work. In other cases it may be necessary to use re-living or re-scripting techniques to allow reprocessing of traumatic events. Should this be the case it is important to have self-destructive behaviours under control and self-soothing skills in place.

Dissociation is often a response to severe trauma and should be addressed early in the therapy or else it may prevent in-session information being processed and so make the therapy ineffective.

These processes do not necessarily happen in the above order and may be re-visited during the work. They are described in order to help the therapist think about what needs to happen in order to enable the client to progress in their life.

• Emotions and Exposure. Learn to identify, experience and regulate emotions. Many people have emotional regulation problems. These may include an inability to fully experience emotions, to label them accurately, to report them to others and to validate one’s own emotional responses.

Being driven to act on emotions is characteristic of impulsive behaviours which can create their own problems. Learning about emotions and how to handle them, to distinguish between ‘warranted’ and ‘unwarranted’ emotions is essential for therapeutic success. Mandy could not bear the feelings of rejection and worthlessness when she heard her mum’s voice. It was important to learn that being rejected is a terrible thing for all of us and it can be borne. Also that her feeling of worthlessness and shame were unwarranted emotions and could be replaced by self-compassion.

• Skills. Learn to handle thoughts, urges, flashbacks, images, etc. Central to mental health problems, in addition to self-loathing, is rumination. Overly negative (or overly positive) thoughts often drive the behavioural urges and problem behaviours themselves. Learning to relate differently to one’s thoughts is an essential skill to learn if we are to be free of the mistake “I think therefore I’m correct”. CBT+ uses mindfulness approaches,

12 December 2017

It may be that some readers find themselves thinking “well, that’s just ACT” or “just CBT” etc. We think that may be a good sign that CBT+ is so congruent with all of the approaches. We also hope that it adds something extra. That is, the ability to freely use the resources of each approach to the benefit of the client, but in a considered way with focus on the process.

Applications of CBT+ By starting with a self help approach we have taken the client’s perspective and shared their journey through therapy. We believe this approach can be used in many contexts, from self-help to supported self-help to being used by experienced therapists as a guide to their practice. We have experience of teaching this approach skills to volunteers with no previous experience, such as in an Indian mentoring programme for disadvantaged children. Giving a basic understanding and teaching skills is one way of addressing the massive global shortage of mental health, wellbeing and resilience resources. The NAVIGATE framework can help achieve this. It is also important to give guidance as to how to stop when out of one’s depth.

In summary, whether for therapists, for professional and voluntary workers in other contexts, or as selfhelp, CBT+ can offer a way for all of us to harness the energy of the third wave.

feature

The ABC of CBT in a nutshell As an assistant psychologist working in an acute inpatient psychiatric unit for adults suffering from a range of mental health difficulties, I have been able to appreciate the application of CBT in a highly demanding setting with a range of different presentations. The opportunity to attend the workshop ‘The ABC of CBT: reviewing basic CBT skills and applications’ led by Helen Kennerley at this year’s BABCP Annual Conference was therefore very appealing to me and I decided to fund myself in order to attend it.

Farhana Maleque, an assistant psychologist at the Central and North West London NHS Trust attended the Annual Conference in Manchester, and reviews the ‘ABC of CBT’ workshop by Helen Kennerley

Helen’s teaching was very refreshing. She provided interesting and interactive case examples using basic CBT skills, particularly exploring the maintenance cycles in formulation and highlighting the importance of applying the ABC principles: alliance, behavioural interventions and cognitive interventions. This includes interventions such as relaxation and breathing, distraction and identifying biases, graded practice and relapse management.

Formulation can be defined as a framework that helps to understand and explain a person’s problems; one which guides effective treatment and decision-making. While formulation often applies a recognised theoretical model, it is often that the model doesn’t quite fit the person.

Therefore the importance of conceptualising a client’s presenting difficulties prior to applying a model allows for mutual understanding in order to explore the best option.

Within my current role, I have observed the difficulties in selecting an appropriate model to fit with a client’s complex circumstances. This led me to recognise that both ‘straightforward’ and ‘complex’ difficulties need to be simplified using the ‘less is more’ formulation principle, particularly the client’s background. It is only in the maintenance cycle that I realised that more exploration is possible, specifically in using CBT interventions. I have noticed that by focusing on the maintenance cycle, there are several opportunities to sabotage the person’s patterns that contribute to the presenting problem.

Helen explained that exploring the client's background (specifically ‘why it has affected the person’) requires the therapist to undertake more longitudinal work. However, if neglected this may impact the therapeutic alliance. Therefore, it would seem appropriate to tap into the background and then address the maintaining cycles sooner rather

than later, especially when encountering short admissions.

My service supports a range of individuals with behaviours that challenge through cognitive and behavioural strategies and relapse management.

This support is collected in a coping strategies tool kit. Although cognitive strategies such as distraction can be effective, it is often difficult to carry out behavioural strategies like graded exposure and relapse management within a short period of time.

It seems appropriate to follow Helen’s advice, to touch on relapse management early in therapy and practice graded exposure in each session. The client and the therapist work together in each session to address relapse management issues, graded exposure exercises and the question ‘so knowing that you did this, how do you feel?’. This not only helps the client to practice the skill within a safe place while increasing their awareness of the traps and pitfalls, but also offers them reassurance with the hope that it reduces the likelihood of experiencing a relapse.

Throughout Helen’s workshop, we were guided through case examples and video clips illustrating how to formulate simple and complex difficulties.

We were then asked to reflect on clients we could use our new skills with. This not only enhanced my skills and confidence in applying the basics of CBT with a range of individuals, but it provided me with reassurance with regards to the way it can be adapted to meet the needs of the individual, regardless how complex the problem.

In summary: • Touch on relapse management early in therapy • Regardless of the complexity of a case, work with the client collaboratively and pay more attention on teasing apart each problem and what maintains the cycle • Break the cycle by introducing the aforementioned cognitive and behavioural strategies • Practice the exercises in session • Reflect and ask the question ‘so knowing that you did this, how do you feel?’ to the client The workshop ended with Helen encouraging the need for supervision to ensure effective CBT practice. This discussion would be useful for another workshop. I cannot wait for the next conference. Just watch this space.

December 2017 13

Dr Allán Laville is Programme Director for the MSc in Psychological Theory and Practice across the School of Psychology and Clinical Language Sciences and Charlie Waller Institute at the University of Reading, and has delivered sexual awareness training since 2011

“

For a clinician to meet the criteria of ‘appropriate’ awareness, they need to be aware of the information provided by the patient and whether the patient’s sexual orientation should be considered further.

”

14 December 2017

The importance of data collection, signposting and ‘appropriate’ awareness in working with sexual orientation It is known and detailed by Mind that Lesbian, Gay, and Bisexual (LGB) individuals are at higher risk of experiencing anxiety and depression compared to heterosexual individuals. Furthermore, Ilan Meyer’s Minority Stress Model clearly highlights how stigma, prejudice, and discrimination create a stressful social environment for sexual minorities and that this can lead to mental health problems.

Moreover, a combination of the above factors can lead to risk-taking behaviours as well as suicidal ideations and attempts. Therefore, it is of paramount importance to consider the needs of our patients who identify as LGB. Reflecting on the delivery of my sexual awareness training has enabled me to clearly see the areas of best practice that we, as clinicians, should aim to achieve in our clinical practice. In my CBT Today article from May 2013, Diversity Matters, I outlined the core considerations within clinical practice,

Allán Laville’s article from CBT Today, May 2013

namely; data collection of sexual orientation as a protected characteristic under the 2010 Equality Act, thorough risk assessments, and the importance of signposting. In this article, I am developing the importance of data collection and signposting as well as discussing the concept of ‘appropriate’ awareness.

Data collection As we are aware, it is still the case that access to services and outcomes by sexual orientation are not well understood and information is undercollected. One reason for this is that some clinicians may not be collecting the data needed to accurately assess access by sexual minorities.

Another reason could be due to how the clinician is framing this data collection and whether the patient is clear on why this information is being asked for. This could affect how forthcoming the

feature patient is with this information. A potential result of this is that a patient may respond ‘prefer not to say’ as opposed to stating their sexual orientation. Therefore, we need to collect this data in a sensitive and appropriately framed way.

In the sexual awareness training, we discuss at what point in the care pathway that the information on sexual orientation is collected by the service. We also discuss the use of labels to define different sexual orientations. Using labels or terms to define sexuality can be useful for some individuals as it can bring an end to the confusion regarding their sexual identity.

For others, labels may not be useful and some individuals do not necessarily define their sexuality. Rather, their experiences with and feelings towards others is the most important consideration point. Therefore, it is important to use the patient’s own language when they provide information on their sexual orientation. This may well include terms or phrases that we are not familiar with and therefore, we will need to explore this with the patient in more detail.

sure that the service is sexually sensitive.

Alternatively, the service may want to develop a resource directory and identify an LGB champion within their team to lead on the project.

‘Appropriate’ awareness

For a clinician to meet the criteria of ‘appropriate’ awareness, they need to be aware of the information provided by the patient and whether the patient’s sexual orientation should be considered further.

This assumes that data collection on sexual orientation has been completed.

Signposting The Project for Advice, Counselling and Education outline the main features that are required for a sexually sensitive service. One key feature is that all staff delivering mental health services should be aware of specialist services for LGB individuals. Furthermore, recent research highlights that good quality practice very much depends on the awareness of individual staff members.

In relation to the above, I often find in the sexuality training that some trainees are unaware of the specialist services for LGB individuals within their locality. The opinion is that they will look into specialist services when needed but have not yet done so. However, we then spend some time sharing information about the specialist LGB services that we are aware of. As a result of this discussion, trainees then set themselves an action plan to research the specialist services available in their region.

The point above also highlights the need for trainees to be familiar with their service’s resource directory. If a resource directory is not available, then services may wish to deliver training regarding what provisions are available and to make

In my training, we cover the concept of ‘appropriate’ awareness. In essence, ‘appropriate’ awareness is to; a) consider the patient’s sexual orientation; b) the type of information that the patient is sharing regarding their sexual orientation; and c) what signposting options would be appropriate for that patient.

It is all too easy to assume that someone would like to know about various specialist LGB services just because they identify as gay, lesbian or bisexual.This would not meet the criteria for ‘appropriate’ awareness.Through good information gathering, we should be able to fully assess and explore whether our patient might be interested in these services.

If it has, they need to be aware of appropriate specialist LGB services and also aware of whether the patient is requesting support in this area.

In summary and returning to an earlier point, we need to be aware of specialist LGB services throughout all of our clinical work and not as and when the need to explore these services arises. We also need to provide information on these services when appropriate and not to all individuals who identify as nonheterosexual. This is because for some, these services will be useful whilst for others, they may not be.

“

The Project for Advice, Counselling and Education outline the main features that are required for a sexually sensitive service. One key feature is that all staff delivering mental health services should be aware of specialist services for LGB individuals.

”

December 2017 15

Mental health in low and middle income countries:

A call to action for BABCP? There can be little doubt that the inclusion of mental health in the United Nations Sustainable Development Goals of 2015 marked a significant success for activists who had been campaigning for this for quite some time writes John Minto

Thematically, the SDGs cover mental health in two specific ways – first in the overarching principles “To promote physical and mental health and wellbeing” and, second, within specific targets, such as “By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and wellbeing”.

While advocating for the inclusion of mental health in the SDGs, a number of agencies – including leaders such as the Centre for Global Mental Health and Primary Care Research at King’s College London and major mental health projects such as PRIME and EMERALD – also started to develop plans and frameworks which will support decision makers and those international and national partners working with them in low and middle income countries (LMICs) responsible for the planning and provision of healthcare systems related to mental health. This article summarises emerging issues, while also noting important opportunities for BABCP. While recognising that there can be no ‘one size fits all’ for mental health systems within LMICs, there are positive signs in relation to; (i) the recognition of the burden of disease re mental illness; and, (ii) evidence-based decision-making with regards to a balanced care model of mental healthcare provision. For example, within the context of Africa’s largest country by population, Nigeria, it has been greatly encouraging to see the inclusion of the screening and treatment of depression in the country’s National HIV-AIDS Strategic Framework 2017-2020.

This has come with an increasing recognition by decision makers and ‘society at large’ of the need to address mental health within the context of a range of comorbid chronic illnesses and a large ageing population. Part of the reason behind this recognition has been a growing awareness that for example, for someone living with HIV-AIDS, the impact of depression could result in late presentation to care, poor adherence to treatment and equally poor overall health seeking behaviour, including a poor diet and inappropriate sleep patterns.

Within low resource countries in particular, there has been growing recognition that, in terms of mental health; (i) most resources should be allocated to staff and other community members at the primary health care level; (ii) skills development for identified primary healthcare workers should focus on case identification, assessment and therapies such as CBT; and, (iii) the limited number of mental health specialists should be leveraged to build up skills within primary health care settings and should also be on hand for referral purposes.

But this is in an ideal world and the extremely limited number of mental health specialists in

16 December 2017

feature most LMICs is deeply challenging and has even been recognised as a limiting factor in the impact of the World Health Organisation’s Mental Health Gap Action Performance initiative.

There is also growing recognition of the importance of engaging structures and personnel from outside the healthcare sector in order to achieve SDG mental health targets. Population level activities including health campaigns, appropriate legislation and regulations are increasingly seen as essential and have also been shown to be cost effective. Community level interventions such as learning programmes at school, appropriate parenting initiatives and the training of community gatekeepers have also been shown to be highly effective.

Within the growing evidence base related to mental health within LMICs, there is also emerging an enhanced awareness of the challenges which often stubbornly remain in place with respect to effective initiatives. These can be classified as follows: First, at the ‘society’ level, in many LMICs, there is significant disregard – which often includes the violation – of the human rights of people living with mental illness. In such circumstances, stigma and discrimination levels are high and tend to reflect the lack of engagement of ‘users and carers’ within the context of, for example, policy making and stigma reduction campaigns.

Second, at the level of health system organisation, most LMICs are set up within the context of a silo framework, focused largely on the identification and treatment of communicable diseases such as HIV and TB. There are few mental health programmes from which lessons can be learned, while results and lessons learned from the monitoring and evaluation of treatment outcomes are also exceptionally thin on the ground. The funding of mental health systems is simply not a priority for most LMIC governments, which has led to the claim of institutional discrimination from some sources. This is particularly troubling given the now well-established data related to the burden of disease.

Third, and linked to health system organisation, most LMIC governments – and, indeed, private sector interests – give mental health extremely low priority and consequently there are few mental health policies in place which are being funded and implemented to any form of appropriate standard. This in turn is reflected in a lack of appropriate treatment sites, little or no engagement with traditional healers – who are often the first source of ‘mental health’ care – out of date legislation and poor or non-existent health insurance cover for individuals.

The Programme for Improving Mental Health Care (PRIME) is a six-year initiative in Ethiopia, India, Nepal, South Africa and Uganda supported by UK Aid. The goal of PRIME is to generate world-class research evidence on the implementation and scaling up of treatment programmes for priority mental disorders in primary and maternal health care contexts in low resource settings.

Emerging mental health systems in low and middle income countries (EMERALD) is supported by the European Commission and working in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. The objective of the Emerald Project is to improve mental health outcomes by enhancing health system performance. Specifically, the Emerald Project aims to identify key health system barriers to, and solutions for, the scaled-up delivery of mental health services in low- and middle-income countries (LMICs), and by doing so improve mental health outcomes in a fair and efficient way.

India

Nepal

Ethiopia Nigeria Uganda

South Africa

Continued overleaf December 2017 17

feature Mental health in low and middle income countries: A call to action for BABCP? Continued

Fourth, and a reflection of the levels of stigma and discrimination present in most LMICs, there are few, if any, user-led advocacy initiatives aimed at lobbying government and international partners.

There is also a striking absence of user-led movements which could also advocate for the capacity building of peer and selfhelp support services. The unfavourable comparison with HIV-AIDS support groups is striking.

Fifth, and perhaps most pertinent for BABCP, there is emerging evidence to suggest that perhaps the most critical issues being faced within the context of mental health in LMICs at the current time are; (i) the lack of trained healthcare professionals; and, (ii) the need for leadership within the mental health ‘community’.

As far back as 2010, World Psychiatry noted that, within LMICs, mental health professionals were not sufficiently engaged in policy formulation and resource allocation plans at the international, national and regional levels.

Many mental health professionals trained in LMICs move into private practice or become part of the ‘brain drain’, and this is entirely understandable under the circumstances. This results in a dearth in numbers of mental health professionals, which has significant implication for in service training, supervision of primary healthcare workers, staff turnover and burnout. It is also noted that within the context of professional bodies that there is evidence of some degree of resistance to community-based care and the engagement of service users.

This lack of expertise is particularly troubling due to the fact that initiatives focused on addressing the ‘treatment gap’ between the numbers of people needing treatment and the number of trained professionals available to provide it tends to be based on ‘task shifting/sharing’ within the context of primary health care staff in the first instance. With a limited number of specialists available, concerns have been raised over ongoing supervision and treatment outcomes.

18 December 2017

There have been calls for international organisations such as BABCP to become involved, not only in systems level planning, but also with regards to the training of trainers, initially within the context of therapies such as CBT which have been shown to be effective across a number of LMICs (including the Friendship Bench in Zimbabwe which is currently showing the efficacy of developing people into their own therapists – a central aim of CBT).

Equally strong calls have been made for national and international professional associations, again such as BABCP, to become engaged in the conversation

with LMIC medical schools, through which specialists and general practitioners can be trained and supported appropriately.

With the ‘battle’ having been ‘won’ in terms of the inclusion of mental health within SDGs, there is a clear opportunity for BABCP to engage with LMIC and other policy and decision makers, as well as community gatekeepers of all descriptions to help address the ‘treatment gap’ in ways which are cost effective and, in the lingo of the development world,‘sustainable’. Perhaps as a starting point, BABCP could reach out to and organise discussions with the leaders of EMERALD and PRIME?

BABCP President Chris Williams responds BABCP is an organisation whose purpose is widely to promote CBT for the good of the public. We do that in a variety of ways within the UK and Ireland (membership, branches, training, SIGs, accreditation, workshops, journal, research fund etc). We know that many BABCP members individually take part in teaching and research overseas in LMIC countries. We are fortunate enough to be based in a wealthy country and as an organisation have been looking at ways of helping build CBT infrastructure outside the UK and Ireland as well as inside, however this has often been individual small pieces of work rather than anything more sustained.

For example: In the last year we have: • Introduced an Associate membership which is aimed at people in developing countries who are interested in promoting and researching CBT. • Arranged with Cambridge University Press to allow fifty key articles to be placed on our website at no cost to the reader - both for members and for those who are not - especially with the developing world in mind. The choice of article is being chosen by the Equality & Culture SIG. Cambridge have also told us that they have a significantly reduced rate to allow access in libraries of LMIC countries.

• At the 2017 conference in Manchester we funded the attendance of Haimraj Hamandeo of the Guyana Foundation.

With time we hope to build a video training bank and resource of worksheets and handouts for members to use in this country and elsewhere. As a Board we are keen to support such developments and although our focus will always be predominantly in the UK and Ireland, we wish to support development of CBT further afield.

We will be inviting the Equality & Culture SIG to work with the Board and others to make some specific and costed proposals about how we can develop this work in a sustainable way. It would be great if any BABCP members with a global health interest could also volunteer their time and expertise from time to time to support this work.

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As cognitive behavioural therapists we are expected to use behavioural and cognitive theories to inform our practice of psychotherapy, writes Warren Mansell

What if these theories fail to rid us of simple misinterpretations that we can make of our clients' behaviour? If so, how easily might we, as therapists, be misled in our everyday practice? Could there be an alternative perspective on behaviour that helps us here, and could be used to inform our psychological therapy?

At the University of Manchester, our research group uses a theory known as perceptual control theory (PCT; Powers, 1973) to shed light on the nature of behaviour. We conduct basic science experiments as well as evaluating therapies (e.g.

Method of Levels; the Take Control Course) and service delivery innovations (e.g. client-led booking) based on PCT. In this article, I want to share with fellow CBT therapists some insights from a series of basic science experiments we carried out recently (Willett, Marken, Parker & Mansell, 2017).

We carried out three studies on the same phenomenon - that we called 'control blindness'.

The members of public in the study were told they would see a video of two people drawing on a whiteboard, with their pens linked by a rubber band. On the right was the experimenter's pen, and on the left was a volunteer's pen. The participants were asked to watch the video closely and simply work out what the volunteer had been instructed to do.

Across the three studies, only a tiny minority of people guessed correctly. In fact, our second study of 236 people included 34 mental health professionals and yet no groups of professions were any better at their guessing.

See if you experience the illusion too when viewing the same situation as our study participants. If you can access the internet right now, go to the 30-second video at https://m.youtube.com/watch?v=Zot0HqETp3U. A freeze-frame from the video is shown below. The question to answer is:‘What had the volunteer on the left been instructed to do?’

Most people guessed from versions of the following: 'to do the opposite of the experimenter', 'to do a mirror image of the image on the right', or 'to draw a picture'.

None of these are correct.

The volunteer had actually been instructed to keep the knot of the rubber band on a black dot in the centre of the board. The complex trace left by the pen was merely a side effect of the volunteer trying to control the location of the knot. To do so the volunteer had to pull against the movements of the experimenter in the observed pattern.

No one out of 104 people viewing this video at a university open day got it right.When we recruited through social media for people to view in their own time, it went up to 13%.We even asked 40 people to focus their attention on the knot throughout the video and only five of these got it right.

We think we have created a visual illusion here that reveals a widespread bias in how we all interpret behaviour. We tend to assume we know the intention behind someone’s behaviour. But at times, our impression as observers can be at complete odds with the real intention. This is because when a person carries out any action, he or she does it to control a perception (like to keep seeing a knot over a dot) – people don’t carry out an action for the sake of the action itself. In other words, behaviour is the control of perception. The types of perception we control vary widely – our distance from someone when we are chatting to them, our sense of safety, our self-esteem - are all examples.

So what does this mean for us as cognitive behavioural therapists?

Imagine that the pen movements you observed are our clients’ symptoms, and the client’s goal is, for example,‘to never feel anxious’ or ‘to never remember my trauma’. Now, the complex mental and behavioural process and the symptoms of the ‘disorder’ – panic, worry, avoidance, depression, substance abuse – are actually just our clients’ varied ways of keeping anxiety at bay, or of keeping memories suppressed. Behind the complex picture of a mixed diagnosis is a simple goal – an experience that our client is highly invested in controlling above all else.

If we take this view on board, instead of focusing on helping people to engage in new behaviours or new ways of thinking, we should simply be helping people to better control the wide range of things in life that matter to them. What might seem helpful to us, can only be judged by our clients themselves.

Taking this to its logical extreme, it is more important to help our clients understand their own experiences and goals from their own perspective, rather than to require a shared formulation or to suggest interpretations, techniques or homework.What we are describing here is a highly client-led version of cognitive therapy that we call Method of Levels.

Of course doing basic science experiments is only part of the picture. We need to evaluate new interventions and help them to be as accessible and efficient as possible, as well as being effective.

But, I wonder, as a professional therapist, whether you would have thought it possible to be so misled about the nature of behaviour, without taking part in such a simple, but stark, illusion?

December 2017 19

Health, Work, and IAPT An update on BABCP activity by BABCP’s Senior Clinical Advisor Lucy Maddox and President Chris Williams

Is work always good for us? How can access to psychological therapies be improved for people who are struggling to return to work without putting them under extra pressure that may make them feel worse?

How can vulnerable populations be supported to have equal access to services and still have true consent and agency?

These are some of the dilemmas which arise when considering how healthcare interventions, in particular for anxiety and depression, relate to return-to-work services.

This is one of several domains that Improving Access to Psychological Therapies (IAPT) has been involved in across England, and it is a hugely sensitive area to navigate, with important clinical and ethical areas that need consideration.

As BABCP President, Chris Williams previously presented on this at the Work and Pensions Select committee in 2016. BABCP positively welcomes the idea of trying to help people with depression, anxiety and who struggle with chronic problems in any setting. It therefore seems very worthwhile to consider how help might be offered for those out of work or struggling at work, but there are various dangers where implementation could introduce practices that are harmful.

BABCP continues to work as part of a collective of five major psychotherapy organisations (the other four being BACP, UKCP, BPC and BPS) to provide information to the DWP about varied pitfalls in implementation that might occur, to flag key concerns and suggest ways of working which would minimise these concerns.

The following are some key areas that we have flagged to the DWP:

“

How can vulnerable populations be supported to have equal access to services and still have true consent and agency?

20 December 2017

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1. Clarity of service context: It is important to be clear which inputs are health (IAPT) and which are DWP. Both have different staff, different staff trainings, different cultures and procedures.

Therapists from a health background have been concerned about the interaction between both components. Being clear, transparent and ensuring that clients, therapists (health) and DWP staff all know about information sharing and which staff are employed in which service will help address the points below relating to consent, confidentiality, and motivation. In relation to this it must be very clear that employment staff cannot make health assessments or diagnoses, as this needs to be

feature done by a trained health professional. DWP and IAPT staff offer separate and distinct interventions and are part of different professional groups.

2. Consent: Issues around consent for therapy need to be considered even more carefully than normal because people experiencing mental health problems may be more vulnerable.

Those experiencing depression can be especially vulnerable in this area of capacity to consent.

In addition, there is a potential perceived power imbalance inherent in the relationship between an employment advisor who has input into whether benefits can be drawn and a person who is having to draw on such benefits.

Consent and motivation matter both to therapy outcome and client experience. Engagement with health workers may be damaged by the perceived imbalance of relationship between the client and DWP staff. The power imbalances inherent in depression plus risks of perceived coercion and potential fear of sanctions makes it difficult for health workers to accept direct referrals from DWP staff. To address client vulnerabilities, we strongly believe the decision to self-refer should be made and led by the client.

3. Confidentiality and clarity regarding information sharing: Confidentiality in health treatments is paramount to the ethical code of all healthcare practitioners so information sharing with other agencies, including DWP staff, should only occur if this is asked for and specifically agreed by the client (ideally with written consent), and only otherwise where confidentiality must be broken to prevent serious harm to the patient or another individual. Healthcare services are confidential.

4. Sanctions: Motivation is maximised when there are rewarding experiences, a good relationship with the therapist and a sense that therapy is congruent with individual values. Sanctions are unlikely to be an effective strategy for use with individuals with mental health difficulties. Sanctions are especially unlikely to be effective if someone is experiencing depression, partly because of the physical effects of the illness on ability to get out easily to attend appointments, and partly because of the phenomenon of learned helplessness, where people become helpless to avoid negative situations after a prolonged period of negative experience. There are dangers that sanctions are disproportionately upsetting and damaging to vulnerable people who already can feel overwhelmed and failing because of symptoms of depression. We are concerned that sanctions or perceived sanctions can potentially create hopelessness – one of the biggest predictors of suicide – and believe they should have no part in the seeking or ongoing attendance in healthcare settings. Sanctions should have no part in healthcare services.

5. Routinely listing Return to Work as a focus for therapy in health settings: Whilst there can be many positive benefits to work, it is important to acknowledge that work is not always helpful to mental health and wellbeing and can sometimes be detrimental to mental health. It depends on the type of work, work environment, experience of co-workers, working conditions and pay, and experience with management.

Although the focus of any therapy may relate to work, if the client wishes it to do so, it also may well not be relevant to many individuals who will be focused on addressing other

issues in their lives. Once a client has been referred to health (i.e. IAPT) workers, to properly engage clients the focus of therapy needs to be on areas they wish to work on and must flow naturally from the collaborative assessment. It is not acceptable to mandate that an area of work must be workrelated, or that a target of back to work must be included. To do so would over-rule key clinical concepts of working such as capacity, autonomy, and consent. A client cannot reasonably be expected to be motivated in a therapy where the goals are not theirs but are prescribed. Therapy goals must be client-led.

6. Motivation and engagement: To maximise engagement and motivation, clients need to want to seek help for their own reasons, should be encouraged to work with health workers on areas they see as relevant, with the trust that information they share in health settings will not be further shared outside health settings without explicit consent. Those seeking help should ideally learn to trust and feel able to collaborate because they wish to, rather than because of external pressures such as sanctions. These elements are required to deliver good therapy. Our concern is some of these key elements may otherwise be ignored, downplayed or overlooked. These key elements of the context of therapy must be adhered to in order to ensure it has the potential to be meaningful and effective.

We have recurrently made these points in the hope that they will be helpful to the DWP in their service planning and we are continuing to liaise with the DWP and other major psychotherapy organisations to highlight areas we have concerns about or clinical opinions on with a view to whatever is offered being genuinely helpful to clients.

December 2017 21

Q and A Q. What made you want to work in talking therapies?

Q. And fears?

A. That innovation becomes too theoretical or technical, meaning that core elements of change get overshadowed, such as kindness and compassion in the client-therapist relationship, or even in the relationship that clients have with themselves.

A. I have always had an interest in

people, and trained initially in psychology. I was fascinated by the way in which research could advance theory or knowledge. As a research student, I then got the chance to help at a centre offering group therapy for women struggling with depression and anxiety. I could see first-hand the power of talking therapies in changing lives.

From then, I was keen to get active both as a clinician and as a researcher.

Q. What other job might you have done?

A. As a teenager in Ireland I was very interested in all types of music, and worked through all my grades in the piano with a fair degree of enthusiasm.

However, a growing awareness of an incongruence between how pieces should and were being played, led me to conclude reluctantly that music had to be a hobby rather than a career. I pored my disappointment into writing, until I discovered psychology as a subject area.

My fate was sealed as I took up residency in the psychology section of my local library. I later joined my big brother in Southampton and stayed in that fantastic city for 10 years.

Q. When did you join BABCP and why?

A. I joined BABCP while doing my CBT

training at Queens University Belfast in 2012. I was very keen to meet like-minded others, especially those in IABCP, the Irish branch of BABCP. I have attended and presented at the annual conferences of both since that time.

Q. What advice would you give someone starting working in CBT? A. Get involved in committee life and help make things happen at local, regional or national level. Tweeting for instance is a really great way to meet others, have fun, and keep up-to-date with events and new or fast-moving news stories. For any IABCP members particularly who would be willing to help with social media, full training and supports are available.

22 December 2017

Q. What has been your best working moment?

BABCP and me

Dr Ann O’Hanlon is a psychologist, supervisor and DAKtivist (daily acts of kindness enthusiast) who serves on the IABCP committee Q. Who is your biggest hero?

A. One of my biggest heroes is Dr Aaron T Beck. He is a genius – way ahead of his time, and with books that are still very informative, exciting and inspiring. A highlight for me was meeting his daughter last year at the European EABCT Congress in Sweden. In her address Dr Judith Beck gave insights into his life and his contributions to knowledge; she recommended delegates read and re-read his original works and this is a recommendation I have taken to heart.

Q. What are your hopes for talking therapies over the next five years?

A. That we innovate and apply new insights to marginalised groups, including those for whom CBT may not yet be on the radar, such as those unemployed.

The Condition Management Programme (CMP) for instance is a CBT-informed multi-disciplinary programme that operates across the five Trusts in Northern Ireland.

A. Every day is great. I absolutely love going to work each day, and working towards clients’ goals and towards ‘better’.

It is a privilege to hear their stories, and a real joy to share in their curiosity and excitement as they meticulously review their survey scores from one week to the next, try out new techniques, or report back on new insights from homework tasks. Their courage and inner strength leave me feeling amazed and inspired, especially the courage needed just to try.

Bigger celebrations are also a lot of fun, e.g. when clients have achieved something that has not been possible for them often for years or decades such as finding employment or going shopping by themselves.

Q. Name five people (dead or alive) that you would invite to a dinner party?

A. My parents – very fine role models;

Santa Claus – an expert in gifts for every diner; George Formby – a fantastic actor, singer-songwriter and comedian (and guaranteed to bring out the smiles with his ukulele); and Nelson Mandela – a huge political figure and interesting conversationalist.

Q. How would you like to be remembered?

A. As a kind person though my preference would be to enjoy right now with loved ones, and have them do the same.

branches and special interest groups Supervision SIG and Equality & Culture SIG

North East & Cumbria Branch presents

presents

A practical guide to the role of supervision in supporting therapists work with cultural, religious and sexual diversity with Dr Andrew Beck

9 February 2018 London

Interpersonal Process in Therapy and Supervision with Dr Stirling Moorey

5 February 2018 Durham

Doing it Better: A Masterclass in the Understanding and Treatment of Obsessive-Compulsive Problems in Adults and Children with Professor Paul Salkovskis

22 & 23 March 2018 Grasmere

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

Devon & Cornwall Branch presents

Couples SIG presents

Working with interpersonal trauma in relationships with Dr Marion Cuddy, Dan Kolubinski and Dr Michael Worrell

Integrated CBT and Third Wave Therapies 26 & 27 April 2018 Buckfast

22 & 23 January 2018 London

December 2017 23

Calling all those who work with Low Intensity Cognitive Behavioural Therapies!

The development of the Improving Access to Psychological Therapies (IAPT) programme led to huge investment in the training of Psychological Wellbeing Practitioners to ensure the availability of Low Intensity Cognitive Behavioural Therapy across England. We are aware however, that there are a large number of practitioners delivering low intensity interventions across various settings in Scotland, Wales and Northern Ireland who have not received this training and as such are likely to be working in different ways.

The main aims of the LISIG are to: • Promote and develop evidence-based practice amongst practitioners involved in the delivery of Low Intensity Cognitive Behavioural Interventions • Develop a multi-professional network of support and guidance for practitioners providing Low Intensity Cognitive Behavioural Interventions • Provide a multi-professional hub to support the growth of innovation, research and development of Low Intensity Cognitive Behavioural Interventions across the UK • To support Continued Professional Development (CPD) opportunities for all practitioners involved in the delivery of Low Intensity Cognitive Behavioural Interventions

The Low Intensity Cognitive Behavioural Therapies Special Interest Group (LISIG) was established in January 2017 with the ultimate aim of connecting and supporting all Low Intensity Cognitive Behavioural Therapists across the whole of the UK

We held our first AGM in September 2017 following the Northern Psychological Wellbeing Practitioner conference in Sheffield. This gave us the opportunity to meet with members and hear their thoughts on how the LISIG could help to develop, support and innovate the Low Intensity workforce across the UK. One of the main objectives for the LISIG is to plan CPD events that are relevant and useful to Low Intensity Therapists. Although other BABCP branches and SIGs have provided CPD events that have been available to Low Intensity Therapists, feedback from the Low Intensity workforce has highlighted that not all CPD events are directly relevant or appropriate to the Low Intensity role.

We are also conscious of the fact that Low Intensity roles differ across the UK and that availability of relevant CPD across the four countries is likely to have been variable over the past few years.

With the above in mind, we recently issued a survey to the members of the LISIG to find out more information about the CPD topics that Low Intensity Therapists would like to see available over the coming year. The most highly requested CPD topic was a refresher of the Low Intensity Psychological interventions, with one respondent summing this up perfectly as ‘Doing the Basics Brilliantly’.

(Left) LI SIG committee members Lisa Atkinson, Liz Kell, Liz King and David Rae

24 December 2017

branches and special interest groups Based on this feedback we hope to plan a CPD event that allows Low Intensity Therapists to revisit the evidence base, refresh their knowledge and skills of Low Intensity interventions and consider how best to motivate and engage clients. Our intention is to take this CPD event on a roadshow to four different locations across the UK during 2018 to enable as many Low Intensity Therapists as possible to attend.

If you would like to join the Low Intensity Cognitive Behavioural Therapies SIG or find out more information then please email lowintensity-sig@babcp.com. We are also keen to hear from any branches that are interested in collaborating with us to deliver CPD events.

Committee Members Liz Kell (Chair) qualified as a Primary Care Graduate Mental Health Worker in 2005 from the University of Central Lancashire (UCLan). She has worked within Primary Care Mental Health care for over 10 years in a variety of roles including Clinical Service Manager and Supervisor. Liz is now a Senior Lecturer in Psychological Interventions and PWP Course Lead at UCLan. Heather Stonebank (Secretary) has over 12 years of experience working in the NHS. She qualified as a PWP in 2009 from the University of Sheffield. Heather is a Lead Psychological Wellbeing Practitioner for Sheffield Health and Social Care Foundation Trust and the Lead PWP Clinical Advisor for Yorkshire and the Humber Clinical Network (NHS England).

Lisa Atkinson (Branch Liaison Officer) qualified as a Graduate Mental Health Worker in 2009 from Teesside University and has worked within a number of IAPT services across the North East of England as a Senior PWP. Lisa is currently the Low Intensity Service Lead at Sunderland Counselling Service and Deputy Course Director of the Low Intensity Psychological Therapies course at Newcastle University Samantha Lovely (Treasurer) has worked for Northumberland, Tyne and Wear NHS Foundation Trust for the past 8 years across a number of services including learning disabilities, neurorehabilitation and children and young people. Samantha qualified as a PWP from Newcastle University in 2016 and currently works at Talking Helps Newcastle.

Liverpool Branch look at online CBT provision In September the Liverpool Branch were pleased to host a joint CPD event with Ieso Digital Health writes Elizabeth Forrest.

Branch Treasurer Gemma Ellis and I have been working for Ieso for about a year, and our colleagues often ask us what it’s like to work online. Can the patient see you or hear you? Is it effective? How do you apply CBT techniques in that medium?

So we thought, let’s bring Ieso to us and they can help to answer all these questions.

To begin with, we explored the theory, research and evidence-base around online CBT, before looking at how online CBT is delivered and the positive ways you can use the data collected to improve practice.

Attended by around 60 BABCP members, the event took place in Crosby on a rare sunny day with the beach and Anthony Gormley's statues only a short stroll away which was a great way to stretch our legs during the lunch break.

In the afternoon we had the opportunity for some hands-on experience of delivering CBT online in a live role play scenario, taking it in turns to act as the therapist or the patient. This was a great opportunity to experience the platform which really helped to put into reality what we had looked at earlier in the day.

As a result of the event many delegates said that they were now more likely to consider working online. One delegate commented:“It made me feel excited about the benefits of online CBT as another branch of therapy services could offer alongside more traditional approaches.”

The Liverpool Branch would like to thank Ieso, especially Rebecca Caine, for making this event possible. Please keep a look out for our future events.

You can contact the Liverpool Branch committee at liverpool@babcp.com

Liz King (Ordinary Member) previously worked within Health Psychology and research settings before qualifying from Newcastle University as a PWP in 2013. Liz currently works as a Senior PWP at Sunderland Psychological Wellbeing Service and is an Academic Tutor at Newcastle University on the Low Intensity Psychological Therapies course.

David Rae (Ordinary Member) previously worked for a private neurorehabilitation service for six years as both an Assistant Psychologist and Specialist Support Co-ordinator before qualifying as a PWP in 2016 from Newcastle University. David currently works as a PWP at Talking Matters Northumberland.

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IT Blog BABCP announced earlier in 2017 in CBT Today magazine that “Rather than being a statement of ongoing practitioner competency, accreditation and listing on the register is about having met Minimum Training Standards in CBT and subsequently committing to meet standards which support good practice”

What therapist variables account for clinical outcome in an IAPT service?

How an internet-delivered service can begin to answer this and other big questions writes Sarah Bateup Measuring therapist competency is something that generally occurs whilst we are undertaking clinical training and then, once qualified, in clinical supervision. Measuring competency (in terms of fidelity to the CBT model and adherence to the evidence base) relies on access to live therapy material through audio recordings and video recordings.

Access to such recording relies on the therapist self-selecting appropriate material and offer these to their supervisor for examination using tools such as the CTS-R as well as providing the scores from validated outcome measures such as the PHQ-9, GAD-7 and BDI. The measurement of clinical outcomes in CBT has become common practice and most CBT therapists will be routinely using validated questionnaires to help calculate the effectiveness of the treatment they provide. The IAPT programme has significantly improved the transparency of the effectiveness of primary care mental health service provision in relation to the mandatory reporting of clinical outcome data.

Individual services now have a greater understanding of how effective their therapists are.

Figure 1: An example of an Internet Enabled CBT session

However, it is less easy to understand what cognitive behavioural therapists are doing in the therapy room and why some CBT therapists are better than others. A number of authors, academics and clinicians have become interested in how therapist variables correlate with good clinical outcomes.

With a growing emphasis on increasing access and improving recovery rates it has never been more important to understand the factors that make a therapist effective or ineffective. Understanding these factors will enhance clinical practice, enabling supervisors and trainers to support therapists to become more effective.

Using technology to understand therapist variables Internet Enabled CBT (IECBT) is one method of providing CBT within IAPT. One aspect of IECBT that is novel and unique is the availability of therapy transcripts for every therapy appointment attended. This is the first time that it has become possible to examine live therapy material, at volume, in a clinical setting.

IECBT is a method that uses synchronous written

Live Session Jennine Mayhew 10:27

Thanks for sending me your agenda for today’s session. Before we get started shall we have a think back to our last session?

Felicity Wandsworthy 10:27

Sure. I read through the transcript just before I joined today’s session.

Jennine Mayhew 10:27

Great, that’s a fantastic idea. What would you say were the main things that you learnt from last week’s session?

Felicity Wandsworthy 10:27

Well, I really understand how my thoughts and feelings are linked to what I do. I can see how I get stuck in a vicious circle sometimes.

Send

Type your response here...

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26 December 2017

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branches and special interest groups communication in a secure virtual therapy room. Patient and therapist communicate through typed conversation in real time.

The transcript of each therapy session, conducted in this way, is encrypted and held on a secure site for both therapist and patient to access at any time. An example of a CBT session conducted using this method can be seen in Figure 1.

In addition to a weekly CBT appointment, therapist and patient can also communicate with each other in-between therapy appointments. This asynchronous communication can be used to amplify the effect of CBT by encouraging the patient to focus on between session tasks, goals and consolidating learning that has taken place during a therapy session. Contact with a therapist between appointments tends to be less common in traditional face-to-face CBT. Kessler et al., (2009) demonstrated the efficacy IECBT in their randomised control trial. The study compared the delivery of Internet Enabled CBT with treatment as usual in 300 participants who were diagnosed with major depressive disorder. The 113 participants that were in the intervention group and 97 in the control group were followed up four months after the intervention. In the intervention group 43 (38%) patients recovered from depression (Beck Depression Inventory score <10), versus 23 (24%) in the control group, and 46 (42%) versus 26 (26%) at 8 months.

They concluded that:“CBT seems to be effective when delivered online in real time by a therapist, with benefits maintained over eight months.This method of delivery could broaden access to CBT.”The study demonstrated proof of concept for Internet Enabled CBT.The study demonstrated a statistically significant difference in outcome between the control group and the treatment group.They added that the recovery rate in the treatment arm of the study was equal to the published recovery rates of depressed patients in previous studies using face-to-face CBT. In the last four years over 16,000 patients have completed treatment within IAPT using IECBT. This data builds on the earlier Kessler et al., efficacy study, demonstrating effectiveness in clinical service within IAPT. It is possible to benchmark the clinical outcomes of those patients who have had IECBT, within IAPT, against those who have had face-to-face CBT in traditional IAPT services. This data is reported to NHS Digital and is in the public domain.

Whilst it is established that IECBT is just as effective as traditional face-to-face CBT this method has far more to offer. When you put a computer between a CBT therapist and a patient you develop a data set that has the potential to reveal the answers to many important questions and these answers can help us be more effective as clinicians. This data set has enabled us, for the first time ever, to understand what the best therapists are doing with their patients and, conversely, what the least effective therapists are doing.

At the time of writing 488 BABCP accredited therapist are delivering CBT within IAPT via IECBT with Ieso Digital Health. The majority of these therapists are also either working as face-toface CBT therapists in IAPT or they have previously worked in a face-to-face IAPT setting as a High Intensity Therapist. As with any group of therapists there is some variance within this cohort, with some therapists consistently (over a period of 12 months) achieving a recovery rate in excess of 60% and other therapists

whose patients do not achieve the same gains. Clearly there are a number of patient variables (such as severity and complexity) that will account for a variance in recovery rates and therefore it might be argued that recovery rates alone are not necessarily an indicator of therapist competency.

In order to understand more about therapist variables, the transcripts of therapists with consistently good outcomes and those with consistently poorer outcomes were examined in order to answer the following question: Are these two groups of therapists doing anything different?

A team of clinical supervisors, who all had experience of teaching and supervising on IAPT High Intensity Training Programmes, reviewed the work of therapists from both groups. The supervisors were blind as to whether each therapist was in the high-recovery or the low-recovery group. The team were asked to undertake CTS-Rs drawn from several completed cases and to make observations about each therapist’s work. This process took twelve months and was repeated by later looking at the transcripts and outcomes from the therapists’ work with patients who had a primary presenting problem of depression, social anxiety disorder or PTSD. Findings The themes drawn from this work were overwhelmingly clear.

Therapists whose patients had higher recovery rates had two things in common: 1. They scored above 40% on a CTS-R 2. An evidence-based treatment protocol was being used and adhered to Conversely, therapists whose patients had lower recovery rates were: 1. Scoring below 20% on a CTS-R. 2. Not using an evidence-based treatment protocol.

These findings confirm the earlier hypotheses of Gyanni et al., and Shafran et al., however there was no correlation between years of experience or the therapist’s core profession and clinical outcome. The therapists whose patients achieved better recovery rates did not tend to have higher academic qualifications or more experience than the other group. These findings suggest that one way of increasing recovery rates and enabling more patients to benefit from CBT is to provide additional support and training for therapists who have a greater tendency to drift away from the model.

Having an ability to truly understand therapist competency may seem somewhat disconcerting but it need not be. Most of us work as therapists because we wish to make a difference to people’s lives and, most of us want to become the best therapist we can. Technology is just one way of understanding what good looks like and sharing this understanding enables more patients to benefit too.

Imagine a world where technology plays a part in enabling therapists to be the best they can be…

December 2017 27

branches and special interest groups West Midlands Branch presents www.babcp.com

South East Branch presents

Using CBT to work with Social Anxiety with Dr Jennifer Wild

www.babcp.com

Projects of Passion: Sharing creative practices in CBT

27 March 2018 Birmingham

15 February 2018 Sevenoaks

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

Couples SIG

presents

presents www.babcp.com

Starting up a Private Practice with Jim Lucas

16 January 2018 York

Group Supervision and Networking for Couples Therapists 26 February 2018 London

28 December 2017

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30 December 2017

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32 December 2017