CBT Today Vol 46 Issue 3 (Sep 2018)

Volume 46 Number 3 • September 2018

Under Pressure - Page 8

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

contents Main Feature

www.babcp.com

Volume 46 Number 3 September 2018

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Welcome to our first issue since the Annual Conference in Glasgow. For those who attended, I hope you had a great time - the programme had something for everyone and the city was a fantastic place to visit.

Inside this issue, we look ahead to dealing with the pressures that winter brings, as well as looking at collaborative working and plenty more besides.

Thanks as always to all our contributors - if you have an idea for the magazine, please do get in touch.

Peter Elliott Managing Editor peter.elliott@babcp.com

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Contributors Omara Baig, Andrew Beck, Amy Corbett, Elaine Davies, Bev Edwards, Greg Harrison, Alison Hopkins, Jim Lucas, Patricia Murphy, Rachel Philips, Paul Salkovskis, Ruth Schumacher, James Sparkes, Richard Thwaites, Victoria Whittley CBT Today is the official magazine of the British Association for Behavioural & Cognitive Psychotherapies, the lead organisation for CBT in the UK and Ireland. The magazine is published four times a year and posted free to all members.

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

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

Next deadline 9.00am on 5 November 2018 (for distribution week commencing 3 December 2018)

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

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Under pressure Reducing winter pressures on A&E services at West Essex IAPT by Omara Baig and Amy Corbett

Features 6

The Gulu Sheffield Partnership

12 Special Edition of the Cognitive Behaviour Therapist 13 A level playing field?

14 Running to better health 16 Tips for integrated IAPT services 18 Revisiting approaches to CBT supervision 20 Introducing the concept of good mental health to young teenagers 22 Growing Grit 28 The time is right

Also in this issue News 4-5 d Neil Harmer Awar 10 Accreditation 11 s Jolly good Fellow 19 d SIG 24-27 Branch an workshops

welcome

From the President: Firstly, as the new BABCP President, I would like to thank Chris Williams for steering the Association so well through a tricky period. Chris has ably managed a range of situations and we have become stronger as a result. I am very happy that we will continue to work together for the coming year. I would also, of course, like to thank our members for the confidence they have placed in me by electing me to the Presidency.

The BABCP has grown and changed in the time I have been a member, but has retained and strengthened its core values, something we will shortly be re-affirming. Being larger and more influential, as we now are, brings with it challenges which have to be met by a combination of planning for the future and reacting to what is happening in the present. In terms of how we manage our plans going forward and being ready for the unexpected and unpredictable, our aims can be broadly seen as being about working towards ensuring that the Association continues to become more inclusive and more responsive.

Inclusion Two Special Interest Groups (Women and Gender Minorities Equality SIG and the Equality and Culture SIG) have developed as part of the work of the Association. There is more work to be done in this area and I will do my best to work with others to ensure that we are inclusive of those who find themselves marginalised. Something we will also be working on is the development of the BABCP People with Personal Experience of mental health problems and its treatment (PPE). The aim is to involve service users, their loved ones, people who may not have accessed services but experience psychological problems and so on (hence the term PPE). I believe that the Association will benefit from hearing these and other voices in our plans and current work. At the same time, of course, we also need to pay heed to all members, which brings me to the issue of responsiveness.

Responsiveness There often seems to be tension between the rules that we must observe as a charity and professional body and the need to respond to a rapidly changing landscape in healthcare and beyond.

There are other pressures which affect the organisation; practitioner and professional issues sit alongside but often not fully aligned with research, academic and training matters which characterise us as an interest group promoting CBT. Similarly, branches and Special Interest Groups can and do work alongside the central office, but problems sometimes arise because different priorities may be involved. I intend to work with the board, committees, branches and the membership to improve communication and consider how best we can manage governance issues to ensure that all aspects of the Association are able to respond to what is needed. The scope of such responses ranges from our ability to make media comments in relation to CBT relevant news through to reviewing accreditation processes in the light of feedback and approving branch activities in a timely and flexible way. It is clear that we need to review and consider governance and organisational processes.

There are many things required to improve inclusiveness and responsiveness, but pretty high on everyone’s list is communication, so an early priority for me as President is to consider how communication between the components of a growing and changing organisational structure, with the ultimate focus being our members and those they seek to help.

Paul Salkovskis, BABCP President

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

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We recently issued the following press release highlighting concerns about changes to health education funding and their impact on IAPT services.

The British Association for Behavioural and Cognitive Psychotherapies (BABCP) are concerned about changes to health education funding and their impact for Improving Access to Psychological Therapies.

Improving Access to Psychological Therapies (IAPT) is a programme started in 2008 aiming to improve access to talking therapies for individuals with common mental health problems in England. Over 900,000 people now access IAPT services each year for depression, anxiety and other difficulties.

The government are keen to talk and take action about prioritising mental health and speak of their pride for the benefits of IAPT services.

They recognise that there is an increased need for mental health services especially in children and young people, but across all age groups.

Plans to expand IAPT have been announced, specifically pledging to expand services so that at least 1.5 million adults access care each year by 2020/21. This means an increase nationally from 15 per cent of people with anxiety and depression being seen each year by IAPT to 25 per cent of people with depression and anxiety being seen. There are also

plans to provide more services for more long-term conditions.

This has important resource implications, requiring an increased number of training places for IAPT therapists.

However, funding for training places has now changed.

Previously Health Education England (HEE) had funded education costs and salary backfill during an individuals' training. HEE still funds the training fees but local Clinical Commissioning Groups (CCGs) have only recently been told that they are now responsible for funding backfill. For many CCGs this change occurred after they had committed these funds to other priorities, making it impossible for some to meet the requirements.

This is highly likely to impact on the number of places taken up in September and there are reports that some may not be funding any places in this round of training. CCGs are already facing difficult choices about how to fund mental health and physical health services, and it is not surprising that they may be unable to prioritise IAPT in such difficult circumstances.

This gap in funding will mean a continued lack of trained therapists to provide evidence based talking therapies for people with mental health difficulties. Not enough therapists means long waiting times and patchy provision for people who could be significantly helped by therapies which work.

BABCP highlights this gap that has emerged between funding provision and health policy and calls for urgent action to resolve this. www.babcp.com

Member communications Members will have noticed in recent months that in order to save costs and in consideration of the environment, we have started to shift from mailing information on membership and accreditation renewals, to sending emails. If members are still receiving letters, this will probably be because we do not hold an email address.

Please note that members with NHS email addresses may not receive communications from us as a result of the NHS security systems in place. If members need to check their current email contact details and marketing preferences, please email us at membership@babcp.com 4

September 2018

Compassion fatigue New resources for therapists to help prevent and reduce compassion fatigue are available on the BABCP website. These include individual and systems-based resources and links to several books, articles and TED talks. They can be found at http://www.babcp.com/Therapists/ Compassion-Fatigue.aspx

news

in brief...

Cambridge Core Share: New ways to access and share the latest CBT articles The BABCP journals were established to serve BABCP members, helping them to access, share and publish articles relevant to the CBT community. As part of this BABCP and Cambridge University Press regularly review how to make this as easy as possible for busy clinicians and researchers.

Over the years many authors and other users have begun to share PDFs of journal articles through their own or their institutional websites, and through commercial social sharing sites such as ResearchGate and Academia.edu. Social sharing is featuring increasingly in the news, with some publishers having decided to take legal action against ResearchGate.

BABCP and Cambridge University Press feel that sharing is a necessary and important part of research, and so whilst the sharing of article PDFs raises issues for the long-term sustainability of our journals, we have focussed on providing a viable alternative to the sharing of PDFs to allow authors and readers to share content as responsibly and as easily as possible.

Cambridge University Press has now introduced Cambridge Core Share for both of the BABCP’s journals, Behavioural and Cognitive Psychotherapy and the Cognitive Behaviour Therapist as an alternative mechanism for authors and subscribers to share content. This means that members can use their free online access to the journals to share a free-to-read version of articles in both journals with colleagues around the world.

• Core Share allows anyone who has the right to

view the full text of a journal article – be they authors, institutional subscribers, or otherwise – to easily and quickly generate a URL link that can be publicly shared, including on social sharing sites or social media sites like Twitter. Anyone clicking on the link will be immediately taken to a read-only copy of the final published version of the article.

• This means that BABCP members can use their free member access to the journals to share the latest research with individuals who don’t have a subscription, whether this is therapists in low and middle-income countries or patients or mental health charities.

• the Cognitive Behaviour Therapist twitter feed shares all new articles (and Core Share links) for all tCBT content and highlights from BCP as and when published, so you can now access these articles in full via one click.

• Unlike the sharing of PDFs, we are able to record usage of articles shared via Core Share, so sharing in this way contributes to the long-term sustainability of BCP and tCBT.

Jo Stace Memorial workshop The North East & Cumbria Branch remembered their former Chair Jo Stace with a memorial workshop held at Hexham Abbey in July.

Speakers and delegates from around the country gathered to discuss Jo’s passion, Effective CBT Training and Supervision.

Proceeds from the event of £1,400 were raised for Samaritans.

NICE PTSD consultation BABCP has responded to the recent NICE consultation on PTSD treatment. The expected publication date is 5 December 2018.

Any members interested in being involved in responses to consultations in a specific area please contact lucy.maddox@babcp.com

Paul Salkovskis Editor, Behavioural and Cognitive Psychotherapy Richard Thwaites Editor-in-Chief, the Cognitive Behaviour Therapist Sarah Maddox Publishing Editor, Cambridge University Press

Full details of Cambridge Core Share are available at https://bit.ly/2G36kzV - for details on how to use your member access to BCP and tCBT, go to https://www.babcp.com/Membership/Journals.aspx

Let’s talk about CBT We have had great feedback for our podcast Let's Talk About CBT. Lucy Maddox has been working on more episodes, with the next release due in September.

You can download each episode at http://letstalkaboutcbt.libsyn.com/

Conversion therapy Memorandum of Understanding BABCP were proud to contribute to the launch of the second Memorandum of Understanding against conversion therapy held at the Houses of Parliament in May. Colin Blowers attended on behalf of BABCP board.

September 2018

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The Gulu Sheffield Mental

Health Partnership

The Sheffield Health and Social Care (SHSC) NHS Foundation Trust is the lead UK partner in the Gulu-Sheffield Mental Health Partnership. This article by Partnership Co-ordinator Greg Harrison outlines their work.

Uganda is a low-income country with an estimated population of 40 million and its mental health resources have to compete for funding with other preventable diseases, e.g. malaria.

Northern Uganda is a region recovering from the devastating impact of the terror campaign from the Lord’s Resistance Army (LRA) over many years. The Partnership is concentrating its work in Gulu, which is the main city in Northern Uganda, and has links in Kampala with the service user group and the East London NHS Foundation Trust/Butabika Hospital, which is the only dedicated mental health hospital in Uganda.

The Gulu-Sheffield Partnership is a group of organisations in Uganda and the UK who are developing a two-way learning process for mutual benefit.

In Uganda this involves the Mental Health Unit within Gulu Regional Referral Hospital (GRRH); wider GRRH services; Mental Health Uganda Gulu Branch (MHUGB) a service user and carer organisation; and Gulu University.

In the UK the SHSC Trust is partnered with: • The Commonwealth Fellowship Programme, through the Association of Commonwealth • Universities have supported 23 Gulu colleagues (2012-18) to work in Sheffield • The Sheffield Health International Partnerships (SHIP), a registered charity, allows for fundraising and Gift Aid. Donations are the primary source of funding for the work in Gulu

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Regular communication with the Ministry of Health in Kampala ensures the Partnership works within Ugandan priorities

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• The Clinical Psychology Unit of Sheffield University provides Monitoring and Evaluation • The Gulu Manchester NHS link works in the Medical Wards in GRRH • NHS Health Education England are coordinating links between Gulu Hospitals and its University and the NHS and Universities in the UK

feature Advertisement

The Partnership has a Patient Safety focus and works in GRRH and with MHUGB in the community. The achievements so far include: • The biggest project to date is the development of a community building in Guna, Abwoch. This is a remote rural community with a very strong sense of community that does not have a communal building. Mental health need and suicide rates are high in this area • Developing a dedicated space in the mental health unit to create a children’s ward, recognising the need to provide differently for children and adults, who were previously cared for together • Co-development of a Rapid Tranquillization Protocol with a locally owned audit • The creation of a Medical Library at GRRH, supported by the British Medical Association, Book Aid International and Sheffield Hallam University

RESPECT courses (the ethical management of violence and aggression) began in GRRH in 2013 and was evaluated by Sheffield University/SHSC and published in the African Journal of Traumatic Stress (2015). Gulu RESPECT Instructors have been trained

by SHSC, who have supported their development and course delivery, and they are now training independently. Significant changes in attitudes towards violence & aggression have been achieved.

• Supporting the creation and maintenance of an Occupational Therapy service in the Mental Health Unit at GRRH

One of the Gulu Respect Trainers spent 12 weeks in the UK in 2018 enhancing his skills and gaining a qualification in training staff.

• A bore hole was repaired in GRRH which now serves the mental health unit and other wards • A Mental Health and Epilepsy Awareness Train the Trainers course was provided to MHUGB, enabling them to deliver courses and helping combat stigma in the community • Regular communication with the Ministry of Health in Kampala ensures the Partnership works within Ugandan priorities • Epilepsy Awareness training has taken place both within GRRH and the local community

More information on the Gulu Sheffield Mental Health Partnership can be obtained by contacting Greg at greg.harrison@shsc.nhs.net or Kim Parker, Partnership Clinical Lead kim.parker@shsc.nhs.uk

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Under pressure

West Essex IAPT Service received funding for a six-month period in order to reduce winter pressures at Princess Alexandra Hospital (PAH) accident and emergency department.

Additionally it was hoped that there would be an increase in access to psychological therapies.

Assistant Psychologists Omara Baig and Amy Corbett reflect on the evolution of the project and how it has developed into an example of successful integration between mental and physical health within the NHS.

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September 2018

Healthy Minds is a wave one IAPT early implementer, focusing on a patient-centred model of care. Our service includes PWPs and High Intensity therapists, and last quarter had a recovery rate of 54 per cent, with 70 per cent of patients showing reliable improvement. People with common mental health problems often also have physical long-term conditions (LTC); our service supports those with chronic pain, diabetes and pulmonary conditions amongst others.

It is understood that when mental and physical health problems are treated in an integrated way people can achieve better, so our project hoped to help bridge the gap often present between mental and physical health and provide a smoother care experience for all.

Project set up at A&E Initially we introduced the project into the A&E department and established ourselves in streaming with clinical staff. This facilitated the detection of mental health presentation patterns at first point of contact. We screened and referred individuals who may benefit from our service and psycho-educational sessions were delivered to staff on common mental health presentations and suitability for the service (inclusion/exclusion criteria). We adhered to the hospital policy of medical clearance before they could be referred to mental health services, which resulted in a delay of at least four hours before any contact could be made.

feature Re-evaluation of how practical this location would be for us to be situated resulted in a streaming pathway being created. Service information such as patient leaflets and self-referral forms were left with the streamer with the expectation that they would signpost to the service any appropriate individuals from A&E. Regular check-ups were carried out to ensure the process ran smoothly and any arising concerns were addressed.

On-site GP referral pathway The GPs were identified as a primary point of contact with patients exhibiting health anxiety.

Once again brief psycho-education was delivered to each GP to ensure it was clear exactly which presentations were suitable for Healthy Minds. At first contact materials were left for GPs to hand out to anyone who was suitable, however after reviewing this process and collaborating with staff a brief referral form was created for GPs. This consisted of the PHQ9, GAD7 and a risk assessment, which was completed during the patient consultation.

The process of integrating the service into the onsite GP has been successful; a novel pathway has been established that allows for GPs to refer individuals into the service rapidly by using a brief referral form. Additionally this practice has been encouraged in the local GP surgeries so is likely to have a further positive impact on access to the service.

Diabetes Clinic and outpatients diabetes pathway A key aim of the project was the development of the diabetes referral pathway. The diabetes clinic that was selected had received no psychological input to date, which is in line with research that less than 15 per cent of people with diabetes have access to psychological support. Therefore to amalgamate physical and mental health in this instance a referral pathway was established. This corresponds with a key principle of the NHS Five Year Forward View for Mental Health, which aspires to parity of esteem between mental and physical health. It is hoped that a diabetes pathway will provide better care and outcomes for patients with this long-term condition, as well as reduced expenditure for the NHS.

screened, the doctors would then discuss with their patients if they would like more information or would like to be referred to us if necessary.

Extension of project onto hospital wards The project was extended to the general wards at PAH. It was recognised that many people require support for low mood and anxiety; both patients and staff were considered as potential service users. Each ward manager was approached to discuss our service, the project and it’s aims.

Particular focus was given to wards with older adults and wards that treated chronic LTC, as research has demonstrated that these populations suffer more complications if they also develop mental health problems, which in turn increases the cost of care.

Staff were asked to identify suitable patients.

We devised a direct referral pathway by guiding individuals through the available options for their mental health care, ensuring they received appropriate information, support, and referral to the service if applicable. Any contact with a patient was recorded on their notes to ensure transparent communication between professionals. This practice allowed for appropriate data sharing enabling holistic person-centred care to be provided.

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One of the most important things we learned when engaging with patients is that empathy and clarity are invaluable.

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Staff already have an established system to seek support through occupational health at the hospital. Our project runs alongside and compliments this process as it provides a quicker route for direct referrals through us being present on site, staff have expressed that they found this more convenient.

Continued overleaf

We created a new brief referral form specifically for the diabetes clinics (general/transition/antenatal) for any healthcare professional to use to refer diabetes patients into the service. All patients attending the clinic were invited to complete this form and we were present on site to address any queries the patients had, and completed referrals where appropriate. This method has had the most uptake success; nearly all patients attending the clinic completed their forms and therefore were

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feature mental and physical states are related. We use the terms ‘low mood’ and ‘worry’ to normalise mental health symptoms that are often stigmatised. This allows for a complete conversation that creates a safer environment for patients, encouraging them to open up and begin the recovery process.

Under pressure Continued Reflections Throughout our experience on this project we have learnt that the approach and language used when engaging with individuals in this environment is vitally importance. The service is available for both staff and patients, and each requires a unique approach.

One of the most important things we learned when engaging with patients is that empathy and clarity are invaluable. We found that being clear about exactly what our role is and communicating it in an empathetic manner made all the difference to each patient’s understanding and engagement with the service.

We also found that many patients had not considered the possibility of a psychological component contributing to their illness. Many patients found it enlightening when we assisted them to reflect upon this, helping them to recognise how their

news

Neil Harmer Award The Equality and Culture Special Interest Group was the latest recipient of the Neil Harmer Award for Branch Excellence. SIG Chair Saiqa Naz was presented the award by Chris Williams at the Annual Conference in Glasgow.

The SIG has contributed significantly to CBT Today magazine and written a number of articles which have considered a wide range of diversity issues as well as working with BABCP journal the Cognitive Behaviour Therapist to produce a special edition focussing on Cultural Adaptation.

SIG members work hard to disseminate ideas around the value of CBT into areas where there is little knowledge of this approach to mental health. Most notable has been the workshops that SIG Chair Saiqa Naz has done with several mosques across the north of England which have emphasised the importance of getting the right sort of mental health care and how this can fit well with spiritual and cultural values and practices. Saiqa has also been promoting the work of the BABCP and IAPT services on local radio and print media and led on an outreach session ahead of this year’s Annual Conference in Glasgow.

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We discovered that stigmatism of mental health issues hinder staff in seeking support, due to concerns about being viewed as incompetent. We utilised our person-centred approach to reassure them that psychological input is for everyone and of the confidentiality of our service.

Mental Health Awareness Ending the stigma around mental health is imperative; our role has led to continuous mental health awareness, wellness, and service promotion. This was accomplished by distributing patient/staff leaflets, providing service information materials throughout the hospital, discussions with staff, answering any queries patients may have, attending team meetings, being consistently present on the wards and promotional stands for the service.

Additionally the workforce is being strengthened not only by the staff having access to our service, but also through stress management workshops being set up at the hospital to provide wellbeing support to staff.

We hope we can continue to provide advice and a swift referral process in order to create a comprehensive patient experience where both mental health and physical health are valued equally.

*Statistics quoted are from the NHS Five Year Forward View for Mental Health document

Accreditation

accreditation New Reaccreditation system explained The new annual electronic system of reaccreditation began in July 2018. Here are a few reminders about the new system: What do I have to do?

You will be invited to complete an online declaration comprised of a set of tickboxes regarding your commitment to CPD, Supervision as well as the Standards of Conduct, Performance and Ethics.

The declaration form is emailed to members when they are due to reaccredit – with several weeks in which to complete it and return it by email.

Full details of requirements, the declaration and documents are available at http://www.babcp.com/Accreditation/CBP/CBPReaccreditation.aspx When do I do it?

All fully-accredited practitioners will reaccredit every year on the anniversary of their full accreditation, regardless of how many years ago it was.

If you need to check when your reaccreditation is due, your entry on the CBT Register UK will show the date you were fully accredited – it will be the same date each year. The exception to this will be members who have subsequently received supervisor and/or trainer accreditation. These will reaccredit for all accreditations on the anniversary of the last award.

You must be in clinical practice at the time of making the declaration. If you take a break in practice, please let us know at accred.admin@babcp.com – you will then remain accredited until the same time the following year.

What do I have to submit?

At the point of reaccreditation, you only need to submit your declaration.

Details of CPD and supervision, plus a supervisor’s report will only be requested if you are selected for random audit. Twenty per cent of members who have made the declaration will be selected each month.

Only 12 months of details are required.

What does it cost?

There is an annual reaccreditation fee of £45 which will be due at the same time as your declaration.

This includes the CBT Register maintenance fee. If you pay by direct debit it will be taken automatically, otherwise please contact the accreditation admin office to provide card payment at the time of your declaration.

How to provide evidence that you are accredited Due to the change of process, we no longer supply certificates of reaccreditation. The certificates awarded at full accreditation show the date of the award but not the period of accreditation.

Therefore employers, agencies and members of the public who wish to check if members are accredited should consult the CBT Register UK. Fully-accredited members will be due to reaccredit on the anniversary date of accreditation shown on the Register, unless they have subsequently been accredited as a supervisor or trainer.

If members need further written verification on their accreditation status, and date of their award, they can request this at accred.admin@babcp.com. There is a £10 administration charge.

Provisional accreditation does not denote a lesser standard of accreditation than full accreditation, as the Minimum Training Standards have been met. The provisional period is simply a year at the end of which BABCP checks, by way of a full accreditation application, that the member has maintained good habits of CPD and supervision.

Does my accreditation “run out”?

There is no ‘expiry’ date for provisional or full accreditation. The dates shown on the register are the dates at which the accreditation was awarded and anyone who appears on the CBT Register UK is still accredited. Extensions may be granted for a variety of reasons and BABCP will make several attempts to contact any members who have not applied for full accreditation or reaccreditation at the required time before they are asked to lapse their accreditation.

Other reasons why accreditation may be lapsed include failure to submit your documents for audit, failure to pay your membership and reaccreditation fees when due, taking a leave of absence from clinical practice for more than two years and serious misconduct resulting in complaints being upheld.

Except in the latter case, the accreditation team will again try to discuss the situation with the member before they are removed from the register, giving them opportunities to rectify the situation if possible.

If you lapse, it is a relevant straightforward process to reinstate, however the accreditation date on the CBT Register UK will only show the date from which you reinstated.

September 2018 11

When I first took over as Editor-inChief of the Cognitive Behaviour Therapist (tCBT), I was extremely excited to hear that there was already a planned (and almost completed) Special Issue on Complexity in CBT being guest edited by Claire Lomax and Stephen Barton of Newcastle University, writes Richard Thwaites.

Complexity in CBT

Complexity in CBT is a topic that is relatively little written about and I would argue previously illdefined. Yet it is something that is central to our day-to-day clinical work, particularly the formulations and interventions that we develop and deliver with our patients.

We talk about complex patients and may even use the term complexity as an explanation for those patients that have failed to respond to our interventions, but what is complexity? Are we actually talking about the problem being complex or the person? Is complexity located within the individual or the system around them? And what role does the therapist play in this? What about our wider clinical knowledge of the problem in question? If the patient does have a complex problem(s), how can we formulate this and communicate it in a way that has a shared meaning with our colleagues?

Over the course of the seven articles (and a podcast from Paul Salkovskis and Claire Lomax on the topic) complexity within CBT is examined, discussed, formulated (with case examples) to provide a snapshot of current thinking on this fascinating topic.

In his podcast introduction, Paul Salkovskis asks some challenging questions around the notion of complexity, arguing that many of the patient problems that are currently defined as complex are actually because there is a lack of understanding of the problem, referencing the fact that agoraphobia with panic attacks was once seen as complex before a model had been developed to understand the problem and guide our interventions.

Within the special issue there are articles that attempt to provide a model for understanding what working with complexity might mean in practice. For example, Barton, Armstrong, Wicks, Freeman and Meyer propose key classes of features in depression (biological, psychological and social) that lead to what they define as complexity by interfering with, or complicating, four aspects of therapy: access, readiness, alliance and maintenance factors. This framework provides a language and structure to conceptualise complexity factors and the interplay between them.

The special issue also includes articles on: • How to use simple formulations to achieve change within complex eating disorder presentations where co-morbidity is the norm (Mountford, Tatham, Turner & Waller) • Describing interventions for a young person where the complexity is due to co-morbid and interacting physical and mental health problems (Bennett, Heyman, Varadkar, Coughtrey & Shafran) • Exploring the complexities around delivering CBT

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feature with a population of mentally disordered offender patients (Ferrito & Estelle) • Examining what complexity is, and is not, amongst patients with obsessive-compulsive and related disorders illustrated by five case examples (Sündermann & Veale)

there are different ways to approach the notion of complexity beyond those explored in this issue, such as the work of Delgadillo, Huey, Bennett & McMillan who have used an actuarial, data-driven method of classifying complex cases based on their individual characteristics and their clinical outcomes in order to develop a way of matching therapeutic input to need.

• Exploring and defining the phenomenology of persistent complex bereavement disorder (PCBD) and prolonged grief disorders (PGD) and how this differs or overlaps with depression and PTSD (Duffy & Wild). The authors present a new integrated CBT model for how to work with complex bereavement and grief based on the maintaining processes and interventions within models for related disorders.

Such empirical research and the clinical wisdom contained within this special issue are likely to provoke clinician reflection and debate as to what we actually mean when we refer to ‘complex problems’ or ‘complex patients’, and when we need to develop complex formulations and when we need to keep our formulations simple and maintain fidelity to specific CBT models.

Each of these articles is clinically focussed and based around the experience, knowledge and expertise of the authors and the CBT field. However

I am extremely grateful to the authors who have shared their work and the Guest Editors for bringing a focus to this challenging but essential topic.

This article originally appeared as a Cambridge Core blog post at https://bit.ly/2vO9hlE The special issue of tCBT and podcast are both available at https://bit.ly/2Bfc8ZS You can follow updates and news from the journal on Twitter @theCBTJournal

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Within the Special Issue there are articles that attempt to provide a model for understanding what working with complexity might mean in practice.

” A LEVEL playing field?

There is a growing recognition that gender inequality impacts on all aspects of working life, writes Scientific Committee member Andrew Beck.

One area that many people involved in research have begun to be interested in is how women are under-represented at conferences both in terms of being keynote speakers and having leading roles in other aspects of the programme.

As the CBT workforce and many of the key researchers in the field are female, the Scientific Committee – who organise the programme of speakers at each BABCP Conference - thought it would be important to audit the gender representation at the recent Annual Conference held in Glasgow. This decision was made after the line-up of speakers and workshop leads was finalised, so it gives a good representation of the gender balance without there being a conscious effort on behalf of the committee.

The audit standard used was that there would be equality of gender representation (50 per cent male, 50 per cent female) across all aspects of the conference in the provisional programme.

A summary of the gender split of different aspects of the conference is detailed below. This shows that the BABCP conference generally has a very good balance of male and female presenters in most areas except in skills classes where there are more men and in the symposia where there are more women.

Out of 27 symposia and panels three were all-male and one allfemale. There has been a growing recognition that all-male

Male

Female

Conference committee

11

9

Keynote speakers

8

8

Skills classes

14

9

Workshops

7

8

Symposia

56

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panels are more likely at conferences and many male academics have said that they will not participate in a panel that is exclusively male.

Overall then the gender equality of presenters at the Glasgow conference was encouraging without any specific effort to ensure this by the Conference Committee. This is really something to be proud of as an organisation. In the future it may be a good idea for the committee to query proposals which include all-male panels request that the proposer justifies their choice of participants.

September 2018 13

Running to Better Health Alison Hopkins and Beverley Edwards of Ealing IAPT explain the development of a physical activity programme to help with depression and anxiety.

There is established evidence demonstrating that physical activity has clinically significant benefits for treating a range of mental health problems, including anxiety and depression. The NICE Guidance on Depression (CG90) recommends physical activity alongside guided self-help and computerised CBT. As an IAPT service, we recognise the benefits of including physical activity within treatment, particularly within behavioural activation where physical activity has a natural home.

Behavioural activation focuses on activity scheduling, encouraging people to approach activities that they are avoiding. Evidence suggests that physical activity has a positive effect on wellbeing and mood, providing a sense of achievement or relaxation and release from daily stress. It reduces the risk of depression and cognitive decline in older adults and can also play a part in preventing and treating physical health conditions such as coronary heart disease, type 2 diabetes, stroke, musculoskeletal conditions and some cancers.

Despite this, our clinical experience suggests that clients find it hard to engage with physical activity interventions due to mental health symptoms such as low motivation and withdrawal. Alongside this, therapists are not always confident about referring to outside physical activity interventions; due to lack of availability and not knowing if they would specifically be tailored to people experiencing anxiety and depression. As a result of this and our own personal experiences of physical activity we developed the Running to Better Health programme.

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Evidence suggests that physical activity has a positive effect on wellbeing and mood, providing a sense of achievement or relaxation and release from daily stress.

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14 September 2018

feature Programme development The Running to Better Health programme is based on the NHS Couch to 5K programme and Brain Train self-help guide. It incorporated a local Parkrun – a free, weekly, 5km timed run held in local parks. Our aim was to link in with an established running organisation to ensure social inclusion and sustainability, offering the opportunity to continue indefinitely after clients had completed the course.

It is an eight-week programme, with each session comprising an hour of structured running with a warm up/cool down followed by an hour of psychoeducation which covers advice on activity and wellbeing, the links between mental health symptoms and activity, danger zones, activity diaries, goal-setting and diet. The last session focused on recognising clients’ achievements with the view of setting new challenges.

Facilitators also ran in session to provide encouragement and motivation. Fostering the idea of doing this ‘journey’ together, highlighting they are not on their own.

The ethos of the course was to encourage people to become more active both inside and outside of the session via the formation of WhatsApp groups and sign-posting to local clubs/activities. All of this had the aim of supporting people to connect with others in their community to ensure longevity.

Referral Participants were required to meet the standard IAPT criteria and to be registered with Ealing IAPT service. A Physical Activity Readiness Questionnaire was completed to ensure there were no physical contraindications. One facilitator completed the England Athletics Leadership in Running Fitness course which teaches how to develop safe and enjoyable running experience.

Qualitative feedback included comments on improved wellbeing, being social again and achieving a goal they never thought they would.

In summary the course showed that a structured running programme does help reduce depression and anxiety symptoms and increases individuals’ wellbeing. Although the number of participants was small, we would recommend continued evaluation of the programme and in light of this have a further four courses arranged during 2018.

Challenges We noticed a reduction in participants over holiday periods and a discrepancy between the numbers of participants signed up compared to the numbers that actually started. We discovered that contacting participants a week before the start date acted as a reminder and provided encouragement and therefore reduced the numbers of non-starters.

Referral to the programme continues to be a challenge for several reasons: therapists not feeling confident talking about exercise or forgetting due to other demands. Activity programmes are also not given the same priority as talking therapy.

What next?

Plans moving forward include closer links with the community, developing other sporting modalities and adaption for LTC programmes.

Ealing IAPT services are available online at http://www.ealingiapt.nhs.uk/ and they can be followed on Twitter @EalingIAPT Details of Parkruns around the UK and Ireland can be found at http://parkrun.org.uk and www.parkrun.ie

Results In total, 109 people seeking help from Ealing IAPT service were recruited, with an age range from 21 to 86 years old, with 91 per cent of participants being women. Of the 109 referrals received 79 started the programme and 27 participants dropped out for various reasons. The programme saw a recovery rate of more than 80 per cent for the 52 participants who completed the programme. For those that did not reach recovery reliable change was achieved instead.

Attendance was not an issue; once people have completed a few sessions they tended to complete the programme. We found that the larger the group the smaller the dropout rate, which was possibly due to camaraderie amongst group members.

September 2018 15

Dr Ruth Schumacher (Counselling Psychologist/HIW) and James Sparkes (HIW) share their experiences of job-sharing the successful development of LTC pathways at Health in Mind (North East Essex IAPT).

Tips for

integrated IAPT

services

Did you know that two thirds of people with a common mental health problem also have a long-term physical health problem?

It has been estimated that these people cost the NHS an average of 45 per cent more than those without a mental health problem. The NHS Five Year Forward View set out a central ambition for the NHS to become better at helping people to manage their own health. It identified the need for mental and physical health care services to work more closely together to provide better care for patients.

A particular focus on patients with long-term physical health conditions was recommended for mental health services. It is hoped that the integration of mental and physical healthcare services might better support this population and achieve better outcomes, including reduced expenditure for the NHS. We share our top tips here based on our experiences of what has worked for us as a service.

Have a dedicated/protected LTC Lead role We were fortunate enough to be backed by a visionary CCG, which has been ahead of the national curve in terms of recognising the necessity of focusing on long term conditions. A Lead LTC Psychologist position, held by Dr Rebecca Clodfelter, has been funded in North East Essex since 2015. Her maternity leave allowed us to build on the relationships she established and further develop her initiatives, some of which are highlighted here. In our secondment, we found that not only was it important for the role to be dedicated to LTC work, but also that there needed to be protected space within the role to work away from distractions to focus on LTC development and delivery.

Seek specialist health psychology supervision We benefited from monthly external supervision with a Counselling/Health Psychologist with expertise with long-term conditions. We also engaged in a weekly process of peer supervision by holding checkpoint meetings and reflecting on what we were doing.

16 September 2018

feature Make a road map Taking over this role for a time-limited period, we had to clearly identify what had been done to date, the areas that our service contract required us to focus on and what our main targets were for the year. We identified tier one and tier two priority areas to focus our time and attention on.

Respond to training needs analysis We spent time talking to the whole team in clinical skills group discussions about their concerns regarding working with LTCs, the gaps in their knowledge and how that could be met. This training needs analysis led to mandatory LTC online CPD for all of the team to complete; we also invited guest speakers to our service meetings from physical health services to train our team.

We offered all team members the opportunity to shadow and observe LTC self-management groups and workshops so they could learn more about the population and the skills needed to work with them.

Offer weekly drop-in clinics We maintained weekly drop in clinics for staff to consult us about how to tailor their treatments for people with LTCs. Facilitate monthly LTC breakfasts A free healthy breakfast continued to be a big draw for the clinical team before our monthly service meeting. We took the chance to update everyone about developments, opportunities and answer questions about everything LTC. Proactively market and network We sent LTC promotional posters and leaflets to all GP practices and PPGs in the local area with information about upcoming groups, workshops and the interventions for people with LTCs. We attended as many networking events as possible with physical health professionals and presented information about our service to anyone who would listen.

population had difficulties making self-referrals.

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It is hoped that the integration of mental and physical healthcare services might better support this population and achieve better outcomes, including reduced expenditure for the NHS

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Create health-condition specific self-referral forms We tailored self-referral forms for LTC patients by making them specific to their health condition and replaced mental health diagnostic terminology with words like ‘distress’ and stress’.

Offer workshops and self-management groups We adapted stress management workshops to different physical health conditions and delivered them with plenty of tea and biscuits. We also booked the dates of the LTC Self-management group well in advance so clinicians could always book patients into them – they remain extremely popular and well received.

Co-locate and share resources We co-located with the local Diabetes service.,Two of our therapists work out of their main facility and one of their nurses runs a Diabetes SelfManagement Course with our team members. We emphasised the routine use of mental health screening tools (PHQ 2/GAD 2) by the Diabetes service to identify suitable referrals.

Be tenacious We were not always met with open arms and encountered varying degrees of indifference and hostility from some services. We met these with warmth, openness and curiosity. This approach and persistence largely overcame concerns about our intentions, leading to fruitful collaborations.

We were thrilled to meet all of our priority one goals for this time period and many of our second tier ones too. A number of new referral pathways were developed and access increased. Our LTC recovery rate was a healthy 61.7 per cent with reliable improvement of 72 per cent at the end of our year, much higher than usually seen in this population.

Attend Multidisciplinary Teams (MDT)

We believe part of this success may also lie in the way that the team experienced this type of work as an exciting opportunity and something worthwhile to be a part of, where they felt heard and could grow and develop as clinicians.

We continued to attend MDTs, either virtually or in person, to represent our service and facilitate referrals and appropriate care.

Our experience indicates that IAPT integration can lead to positive outcomes for patients, services and the wider community.

Make a short professional referral form We introduced a new short-version referral form for any healthcare professionals to use to refer LTC patients into the service because we found that this

The Health in Mind service can be found at www.northessexiapt.nhs.uk/north-east-essex and can be followed on Twitter @NorthEssexIAPT

September 2018 17

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Once we are fully qualified practitioners we may add different skills, different models and theories under the umbrella of CBT

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Revisiting approaches to CBT supervision The landscape of CBT has changed over the last sixty years, which gives a variety of knowledge, skill, intervention and techniques, says Elaine Davies.

The services delivering CBT have also changed even more significantly with the introduction of IAPT. No doubt there will be supervisors of all orientations being part of these services offering good quality supervision. Once we are fully qualified practitioners we may add different skills, different models and theories under the umbrella of CBT, even choosing to change modalities.

However, I am concerned that if we have supervisees with plenty of skill and knowledge but who may drift from the original model of CBT then for trainees this reduces competence. If we ‘drift’ in supervision especially in the early first training of CBT this could impact on a trainee’s coursework results, confuse the supervisee in approaching the right technique at the right time and could possibly lead to a lesser outcome of recovery for the client.

In supervision we are reminded of the many plates the supervisor has to keep spinning. The context, the relationship, the skill of the practitioner, ethical and boundary awareness, safeguarding and risk, client focus, overall casework, development of professional style and in this current climate developing practitioner resilience.

It is widely accepted that the relationship and the interpersonal process between supervisor and supervisee makes a difference in supervision.

18 September 2018

We can only assume when this is all working together, interlocking and interwoven with each other, positively experienced by both supervisee and supervisor then clients will benefit. We have in the past relied on Counselling, Social work, Psychology and Nursing to pave the way.

CBT is now gaining credence in supervision models and there are key texts that come to mind when I think of supervision. They all frame their ideas starting with the supervisory relationship, care for the client, understanding the context of work and consideration of the development of the practitioner.

Francesca Inskipp and Bridget Proctor in their book Making the most of supervision have led the way since the 1970s and it would be foolish not to engage with their idea of normative, formative and restorative task of supervision. They emphasise that the supervisor ought to be clear about the role of supporting the supervisee to enhance the relationship with the client.

Another great text is CBT Supervision by Sarah Corrie and David Lane. The learning for supervision is structured around the PURE supervision flower.

The format divides into four parts, Preparing for supervision, Undertaking supervision, Refining supervision and Enhancing supervision. They describe the supervision flower not as a distinct

feature model of CBT supervision but a visual heuristic for assisting supervisors. There are 12 petals, three in each of the four domains that are concerned with an area of practice. A few petals include – know your brand, choose your interventions, develop the relationship, manage the power and increase your expertise.

Next, I engage with the work done by Mark Freeston and Peter Armstrong ‘the Newcastle model’ of supervision. It has also been given the name of the ‘cake stand’ model. This model is considered the most established CBT framework.

Recently I went on a three-day training in Cardiff where this model was delivered by Mark Latham. It was engaging and allowed me to re-engage with the tiers of supervision, which remind us of context, interpersonal issues and enhancing the learning of the supervisees. All tiers have a particular focus but one without the other means that supervision will collapse. It is helpful to think about supervision in this tiered way. I like to think the rod that holds the tiers in place is the alliance between supervisor and supervisee.

Finally, I like the work by Derek Milne and Ian James who offers a metaphor of a tandem bicycle to help illustrate how their model works. For a moment bring to mind a tandem cycle which takes two to ride without falling over. Both supervisor and supervisee are given the opportunity to be

active contributors for supervision to be effective.

In the main the supervisor will be in the front seat operating supervision having some authority and power over the direction of supervision. Picture the front seat, handlebars and gears being in the hands of the supervisor.

No doubt as the supervisee develops, they can move to the front seat of the tandem. Think of the wheels, the one at the front nearest the supervisor, the task of supervision, the objectives, and the development path. The wheel nearest the supervisor is the wheel of learning. The experiential learning for the supervisee where we can incorporate Kolb’s learning cycle. What holds the tandem together is the frame which can be the scaffolding of supervision? The place where all learning needs are met in various ways.

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In supervision we are reminded of the many plates the supervisor has to keep spinning

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I engage more with my learning when I see it in action or when I can visualise it working. I hope in these few words I have whetted your appetite to revisit or to explore if some of these mentioned are not yet on your radar.

Happy supervising!

Elaine Davies is Senior Lecturer IAPT CBT at Coventry University and Branch Liaison Officer for the BABCP Supervision Special Interest Group

Jolly good Fellows At the Annual Conference in Glasgow, President Chris Williams announced this year’s recipients of Honorary Fellowships in recognition of distinguished service to the Association and the CBT community as a whole.

Professor John Taylor (pictured) was awarded an Honorary Fellowship of the Association in recognition of his outstanding contribution to CBT for more than 30 years.

An active BABCP member for that time, John was elected BABCP President in 2008, a key time for BABCP and psychological therapies, with the launch of IAPT services, commissioning of High Intensity and PWP training programmes, as well as the recognition of BABCP accreditation by all major UK health insurance companies.

Dr Alison Brabban whose specialism in the application of CBT and psychosocial interventions for psychosis has led to roles including NIMHE Lead for the implementation of PSIp, National Advisor for the IAPT SMI programme and Expert Advisor to the NHS England Adult Mental Health Programme.

Alison’s contribution to research in the efficacy of CBTp and the development of competency standards for training, accreditation and supervision of therapists has been recognised internationally, with invitations to train staff at home and abroad.

Dr Ann Hackmann who received a posthumous award, pioneered the systematic use of imagery in changing problematic meanings in cognitive therapy, teaching and publishing widely on her creative and innovative work.

Ann contributed greatly to developing several new effective treatments of anxiety disorders and was known for her pioneering approach.

September 2018 19

EARLY EXPERIENCES:

Introducing the concept of

Good Mental Health

to young teenagers

My children were fascinated by the stories I would tell them as I trained to be a Cognitive Behavioural Psychotherapist at Staffordshire University in 2016, says Victoria Whittley.

‘You did what?!’ My daughter would exclaim, delighted at the prospect of mummy falling over in shops, handling public loo seats or throwing loose change everywhere as my cohort practised modelling for social anxiety or OCD behavioural experiments.

20 September 2018

Her interest, as a soon-be-be teen, developed from the shock-amusement, into deeper enquiry into people’s emotional responses and a wondering why we feel a certain way about so many different things. Fortunately, my new-found passion for CBT, and an ex-journalist’s urge to tell stories, has led to a burgeoning interest from my eldest child into Mental Health. The passing into teenhood, with its gamut of confusion about what to think and how to feel – and why it feels – gave me an idea.

I qualified with Distinction from Staffordshire University’s fantastic Postgraduate course in June 2017, having completed clinical hours in Stafford and Basingstoke. As the wife of an Army Officer life is peripatetic, so private practice has been the ultimate goal. With guidance from my supervisor Dr Ken McFadyen I set up a practice room at my current home in Hampshire and established a fruitful relationship with the local GPs.

feature Alongside my private patients I began to develop a presentation on Mental Health aimed at Year 8s – 12 to 13 year olds. This is the age when thoughts and emotions become confusing, overwhelming and, often, intolerable. How wonderful, then, to have the chance to explain at least how we think this all works. Demystifying this whirlwind I hoped would give the youngsters a handle on what was going on internally, and, possibly even to make sense of some of it.

There is much talk about the lack of availability in services for intervention with children and adolescents. I wanted to begin, in a very small way, to reach young minds and expose them to the concepts of Mental Health before problems set in or intervention is required. We cannot expect our children to know what we know, to know what good mental health is and how to achieve it, or to make the links between what they’re thinking and how they feel, without educating them. It took us hundreds of hours of learning and practice with patients to get our knowledge! My daughter was interested – why wouldn’t her friends be too?

Following a conversation with the Head of Boarding and PSHE tutor at my children’s school I was offered an opportunity to take four Year 8 classes at their forthcoming Wellbeing Festival. I prepared a fortyminute presentation covering topics such as – What makes Good Mental Health? How the thoughtemotion-behaviour process works and differences between each other’s responses, introductions to Depression and the Anxiety disorders and what they look like, Empathy and communication, and what to do if you’re worried.

Each slide was accompanied by illustrative cartoons or interesting images, with interactive questions and responses encouraged. At first it was rather daunting facing a class of my daughter’s friends gazing expectantly, particularly when working life is spent one-to-one with adults! A little self-CBTing about ‘I know what I’m talking about’ and ‘what’s the worst that could happen?’ helped with my confidence and the first class of the day passed encouragingly.

Despite excellent PSHE provision the youngsters had little grasp of Mental Health as a concept, and my daughter steadfastly refused to answer this question!

Many believed that good mental health was only achieved by thinking positively and doing the things you like, and were surprised, even bemused, by the suggestion that negative experiences could help build resilience and coping mechanisms which would strengthen their mental health and help them handle difficulties in the future.

coming on after me’ elicited polarised responses in both thoughts and emotions, which demonstrated clearly how we can feel very differently to our friends, and that everyone’s feelings are valid.

Normalising shifting emotions, particularly at this age, with sudden changes from highs to lows seemed to be well received. It seemed to me important to briefly explain what made Depression and Anxiety disorders a clinical problem, as opposed to a few days of feeling low or anxious.

The youngsters were keen to hear how some of these problems present, and I was aware this had to be age-appropriate and simply put. I also spent time likening Mental Health to physical health, asking what they would do if they broke a leg playing sport or fell in the playground. In some cases, seeking professional treatment was needed – for both physical and mental injury.

Empathy is something I wish we all had more of, so I included a brief look at the concept and, to maintain attention, chose two volunteers to swap shoes and try to waddle around the classroom, to much hilarity. The youngsters quickly spotted the analogy ‘walking in someone else’s shoes’.

To conclude I showed photographs of several celebrities, including Adele, Ryan Reynolds, David Beckham and Prince Harry (mistaken once for Ed Sheeran) and asked the class why they thought I’d put this at the end of the lesson. Over four classes, only one child knew they’d suffered well-publicised mental health issues. I wanted to make the point that, whilst we can do many things to improve our mental health and resilience, problems can and do strike us all – irrespective of wealth, fame or success. And like the discussion we shared about not ignoring the broken leg, there are times when we may need to seek professional help with our emotional health.

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I offered several scenarios to demonstrate difference in emotional response, which they took on board enthusiastically.

Giving them situations like ‘we’re about to go skydiving’ and ‘Stormzy is coming on after me’...

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There were a few insightful questions at the end of each lesson, notably one thirteen-year-old girl who asked how she would be able to spot if a loved one had depression. We’d covered this in the lesson but I was left wondering if she needed a private conversation. The member of staff at the back, I hoped, had noticed this question. I have since reflected on where my boundaries lie as a visiting ‘teacher’ dealing with an emotive subject.

On a positive note, I was warmly received by the four classes, all of whom knew me as someone’s Mum. Equally importantly I did not embarrass my teenage daughter. I am currently offering the lesson to more schools, knowing that Mental Health in our youngsters is a topic that must be at the top of our agenda.

I offered several scenarios to demonstrate difference in emotional response, which they took on board enthusiastically. Giving them situations like ‘we’re about to go skydiving’ and ‘Stormzy is September 2018 21

How to help your clients persevere

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Duckworth is a psychologist in the USA and following extensive research, she came up with a formula to describe how one accomplishes their goals

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22 September 2018

Not all my clients get better, admits Jim Lucas, but many do. I have got evidencedbased CBT interventions to thank for that. So why is it, that despite these effective methods, some clients leave therapy not having made any changes?

I am not the first to ask this question. I have read various hypotheses on the subject citing possible ‘therapist-drift’, a lack of quality supervision and practitioner burnout. I expect they all play a part.

At the start of therapy there is a message I deliver to my clients. It goes like this:“As long as I’m teaching you the right techniques and you’re doing the work in your own time, then as the sessions go by, you should start to see some changes.” Simple.

Overcoming psychological difficulties is far from easy of course. In one sense, it is about establishing new habits and abandoning old ones that don’t work. But it takes persistence and a strong commitment to do your exposure work. When clients are low in mood, routinely engaging in values-based activity can be tricky as the tendency to ruminate pulls you down. Despite the progress people make, withdrawal and isolation can easily take hold again. Sometimes, I wonder if I truly understand just how difficult it is to let go, to trust

my therapist and to keep walking with the foreboding of uncertainty and hopelessness.

On the other hand, it is not too difficult to understand the challenge of keeping up new habits. I know too well, the struggle to regularly eat well, exercise often and prioritise my own self-care above being supremely productive.

Over a year ago, I stumbled on Angela Duckworth’s book Grit: The power of passion and perseverance. I say stumbled, but the truth is that I was looking to understand more about how one perseveres against the odds.

Duckworth is a psychologist in the USA and following extensive research, she came up with a formula to describe how one accomplishes their goals. Grit, she explains, is what helps you remain steadfast in the pursuit of a goal. It is what helps you to keep going when you are faced with obstacles and failure. She observed that too many people tend to idealise talent. When we observe

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somebody showing skill, we say things like “oh, they’ve got real talent”. The trouble with that is attributing expertise to raw talent suggests it is natural to our disposition. We either have it or we don’t.

Grit makes a bigger difference to outcome and shapes how much you succeed at something. Duckworth says that in every instance where talent predicts success, effort counts twice as much. And although people do have certain natural talents, it is the ones who work hard and stay focused that do better.

The formula she created for achievement goes like this: Talent x Effort = Skill Skill x Effort = Achievement Duckworth breaks this down even further to outline her four-step process. You begin with taking an interest. This is step one. Help your clients take an interest in the thing they are avoiding. It could be shame, guilt or fear. Develop a fascination for the emotions or environmental contexts. Get curious and ask questions. Seek to understand them more fully.

Step two is deliberate practice. Do something every day. Take tiny steps and aim to improve. Compete against your past record. Find out what you can do to get better. Seek to learn.

Step three is to connect your practice with a bigger purpose.

Underpin activity with freely chosen values. Sound familiar?

Noticing the bigger purposes in what you do can help you persist. Stand tall, be strong and wise knowing that to keep going is better than giving up.

Step four is to adopt a growth mind-set. Your kids will know about this from school. Back in the 1980s Carol Dweck pioneered the work around fixed and growth mindsets. Within the latter, you are more open to learning and believe that it will help you grow.

This makes it more likely that you will embrace challenges, persist in the face of setbacks, see effort as the path to mastery, learn from criticism and find lessons or inspiration in the success of others. Fixed mindsets see intelligence as static and so effort is avoided, because it appears hopeless.

frustration and anxiety. I only wish I could remember to call on him more often. Still, I’ll keep persevering.

You can read more of Jim’s articles on his blog www.openforwards.com/blog and follow him on Twitter @jimlucascbt

Put these four steps together and you can help your clients grow their grit. We can use it ourselves as well. When I get caught up thinking progress is slow and why does my client keep relapsing, it might be a clue that I’m delaying the difficult work. And I have lost sight of what is needed to persevere.

You too can use this approach when therapy seems to be having little impact. Ask yourself: • How interested is my client in learning something new and how can I influence that?

• How often are they practicing?

• Have they identified their values within their actions?

• How open are they to feedback and becoming more skilful?

One useful purpose in my work is curiosity. It is my trusted friend and advisor. It helps me when I feel like I am drowning in my own September 2018 23

The time is right… … to set up a special interest group for women and gender minorities, say co-chairs of the recently-launched Women and Gender Minorities Equality Special Interest Group, Rachel Philips and Patricia Murphy.

In fact if we’re honest, it’s probably a little overdue. Back in 2014, CBT Today ran a series of special features on Women and Mental Health which coincided with a TEDx CoventGardenWomen Unlabelled event in London.

The event’s aim was to shed light on women’s work and lives, present and future, to challenge social, cultural and politically constructed labels, and highlight the dangers of ‘gendering’ that affect the very existence of both women and men.

Since then, fierce and sustained campaigning by women and transgender groups has continued to robustly push for change and to question existing power structures. We have seen the explosive power of the #MeToo movement, been stunned by the magnitude of the gender pay gap and welcomed admissions of regret from Stonewall, Britain’s biggest campaigner for lesbian, gay and bisexual rights, for failing to work for trans equality in the past.

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We take inspiration from Beard’s concept of power as an attribute rather than a possession and aim to ensure that WOMGENE SIG and its committee represent and reflect the diversity of our association

”

24 September 2018

This latter development is hugely important. The level of inequality and discrimination against trans and non-binary people is alarming. According to Stonewall’s LGBT in Britain – Trans Report published in January 2018, one in eight trans people have been physically attacked by a colleague or customer in the last year. Half of trans people have hidden their identity at work for fear of discrimination and a quarter of trans people have experienced homelessness. This year’s London Pride celebrations were disrupted by trans-exclusionary radical feminists carrying highly offensive placards and the consultation on the Gender Recognition Act has coincided with a disturbing rise in transphobic hate crimes.

Equally significant has been the radical shift away from discussions about race and racism being led by those who are not affected by it. A refusal to tolerate wilful ignorance and defensive behaviour regarding the effects of structural racism has been powerfully articulated by Reni Eddo-Lodge whose award-winning book Why I’m No Longer Talking to White People About Race blasted its way to the top of the news agenda and has subsequently been named the most influential book written by a woman.

Slay in your Lane written by friends Yomi Adegoke and Elizabeth Uviebinene which featured as a Radio 4 book of the week is a personal and impassioned response to the failure of mainstream self-help books to address the uniquely challenging experiences faced by black women who are trying to get ahead.

branches and special interest groups We are now obligated to accept that class, structural racism and gender discrimination disadvantage women and gender minorities in the workplace and there is no reason to believe that CBT therapists are exempt. Many of our patients are experiencing these inequalities and if we are to offer them an ethical service, we have a duty to educate ourselves and do what we can to mitigate against the inequities.

Last year’s Kings Fund report on women and leadership within the NHS found that “unsupportive workplace cultures still present the most significant barrier to career progress for women”. It references a study in 2016 across a wide range of employment sectors which found that amazingly this was the case for female respondents in the 20-29 age group as well as for older respondents. Gender inequality and discrimination were reported, as were difficult colleagues and managers, bullying, undervalued work, and women feeling that they have to overperform simply because they are female. Organisational culture, including the drive for a more inclusive approach to leadership development, is something that is currently receiving considerable attention in the NHS. It is also worth noting that the gender pay gap is significant in UK higher education, another frequent employer for CBT professionals. The worst example is an institution that pays women almost 40 per cent less than their male colleagues.

It is notable in our own organisation that since it was founded in 1972, more than 70 per cent of BABCP elected Presidents have been white men. This falls short of the Kings Fund recommendations of 50-50 by 2020. At present BABCP do not hold data on members’ gender identity although we understand that this is set to change and we would fully support BABCP conducting its own internal research into gender disparity within the organisation.

We hope that by briefly outlining some of the cultural shifts in attitudes towards women and gender minorities and by highlighting the gender disparity in health care, we have gone some way in explaining why the SIG is not only necessary but an important opportunity for members to examine and influence the issue of power within the organisation and our wider society.

In her book Women & Power – A Manifesto classicist Mary Beard argues against power as a possession of the elite few. Rather than finding ways for women and gender minorities to slot into an existing structure, she encourages us to think about power differently, placing an emphasis on collaboration and facilitating the power of followers not just leaders.

We take inspiration from Beard’s concept of power as an attribute rather than a possession and aim to ensure that the WOMGENE SIG

and its committee represent and reflect the diversity of our association. We are painfully aware that our embryonic interim committee is comprised of white, cis gendered women and we ask you to help us change that by getting involved and attending our inaugural event and AGM scheduled for Thursday 18 October 2018.

The event will be held in the stunningly beautiful and historic Old Library in Birmingham. We have curated a day which we think will energise, inspire and entertain. You can find more details of this event in our advert in the back pages of this issue of CBT Today or on our SIG webpage on the BABCP website.

Times are a changing and as an organisation we need to ensure we reflect those changes.

Who better than Maya Angelou to remind us to,“Do the best you can until you know better, then when you know better do better.”

To join the SIG please email us at womgene-sig@babcp.com and we are on Twitter @BABCPW The reports mentioned in this article are available at the following links: • https://www.stonewall.org.uk/lgbt-britain-trans-report • https://www.kingsfund.org.uk/blog/2017/05/women-and-leadership-still-more-to-do • www.bbc.co.uk/news/uk-england-43655192

September 2018 25

Compassion Special Interest Group

East Midlands Branch & CAF SIG

presents

presents

Compassion Focused staff support and supervision with Kate Lucre

Negotiating the challenges and opportunities in the delivery of child and adolescent CBT 13 December 2018 Derby

14 March 2019 Birmingham To find out more about these workshops, or to register, please visit www.babcp.com/events or email workshops@babcp.com

Chester, Wirral and North East Wales Branch

Devon & Cornwall Branch presents

presents

Treating anxiety problems across cultures: A practical guide with Dr Andrew Beck

Compassionate Supervision with Tobyn Bell

28 September 2018 Chester

26 September 2018

25 January 2019 Buckfast

branches and special interest groups East Kent Coastal Branch

East Midlands Branch

presents

presents

Getting creative with CBT With Dave Woodward

2 October 2018 Sittingbourne

CBT interventions for working with Long Term Conditions with Professor Karina Lovell

Treating Body Dysmorphic Disorder and body image problems

5 October 2018 Nottingham

With Professor David Veale 21 February 2019 Faversham

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

Eastern Counties Branch

IABCP

presents

presents

Adapting Brief Behavioural Activation for Young People with Depression

Difficult-to-treat Depression: An integrated approach

with Professor Shirley Reynolds

with Stephen Barton

23 November 2018 Belfast

5 October 2018 Norwich September 2018 27

branches and special interest groups Manchester Branch

Liverpool Branch

presents

presents

Treating infidelity and interpersonal betrayal in relationships with Dan Kolubinski 27 October 2018 Manchester

CBT for PTSD and Beyond with Dr Michael J Scott 4 October 2018

Compassion Focused Therapy from the inside out with Tobyn Bell 6 February 2019 Both workshops will be held in Liverpool To find out more about these workshops, or to register, please visit www.babcp.com/events or email workshops@babcp.com

South East Branch

North West Wales Branch

presents

presents

An introduction to Schema-informed CBT: Theory and practice with Dr Helen Startup and Janis Briedis

8 & 9 October 2018 Sevenoaks

28 September 2018

CBT for social anxiety with Professor David M Clark 5 October 2018 Bangor

branches and special interest groups West Branch

South & West Wales Branch

presents

presents

A compassionate mind approach to recovering from shamed-based trauma and PTSD with Lisa Williams

Adapting Cognitive Behavioural Interventions for Autism with Dr Ailsa Russell

23 November 2018 Swansea

18 October 2018 Bristol

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

Scotland Branch

Yorkshire Branch

presents

presents

Adapting CBT for people with autism – Avoiding the neurotypical trap with Darren Liddle

Developing cultural competence in CBT and reducing inequalities in mental health

23 November 2018 Perth

with Saiqa Naz 19 October 2018 Wakefield

September 2018 29

30 September 2018

September 2018 31

32 September 2018