Low Intensity Cognitive Behaviour Therapy

A Practitioner?s Guide

Mark Papworth, Theresa Marrinan, Mark Papworth, Theresa Marrinan

• Publisher: SAGE Publications Ltd
• Year: 2018
• Print ISBN: 9781526404442
• eBook ISBN: 9781526452245
• Edition: 2
• Topic: Medicine
• Subtopic: Psychotherapy Counselling

This is the essential book for any health professionals whose role incorporates low intensity CBT. It introduces readers to the principles and skills of cognitive behaviour therapy, and guides them through the entire process of working with adult patients with common mental health problems. Beginning at the initial assessment, it takes students through the implementation of interventions to the management of ending. Detailed case studies illustrate each step of patients? recovery journeys. This new edition:

• is updated in line with changes in the PWP curriculum and broader IAPT policies
• includes new chapters on working with older adults and patients with long-term conditions
• adds new exercises to help readers reflect on their own practice, and builds confidence to help them become outstanding practitioners.

1 Introduction

Mark Papworth

Learning objectives

• To understand the fundamental principles of cognitive behaviour therapy (CBT) and low intensity cognitive behaviour therapy (LICBT).
• To know the historical context of the development of CBT and LICBT.
• To be aware of systems of stepped and matched care that support the practice of LICBT.
• To have knowledge of the other aspects of service delivery (for example, service promotion and self-referral), which are required to maximise the impact of the approach.
• To understand the economic argument which justified the English LICBT (Improving Access to Psychological Therapies, IAPT) scheme, and to be aware of the effectiveness of LICBT.

Introduction

The ‘core mission’ of this book is to teach the reader how to perform low intensity cognitive behavioural therapy (LICBT). This is a form of CBT that is used to treat mild to moderate, common mental health problems over a shorter length of contact, through the use of therapy vehicles (such as supported self-help). More latterly it has been expanded to help clients to cope with long-term physical health conditions as well. However, before I turn to this important and fascinating topic, by way of an introduction I look at the varied contexts in which the approach has grown. These contexts have both enabled the development of the approach and are required to support its practice. These might be broadly described as historical (LICBT’s origins), service-related (the arrangement of healthcare services which support LICBT) and political (the economic and political arguments that have driven the development of LICBT). To overview these, this chapter first examines the principles of CBT and LICBT, and then two of the psychotherapeutic approaches that have been instrumental in the development of CBT, the stepped care model of service delivery and latterly the English Improving Access to Psychological Therapies (IAPT) programme.

Cognitive behavioural therapy

The CBT approach assumes that emotions, behaviours and physical symptoms (which are core components of common psychological disorders) are influenced by thoughts, beliefs and images that exist in individuals’ minds. These mental processes are termed ‘cognitions’.

A classic example of this process in action is illustrated by the following situation: imagine that you are walking along a street and you notice that an acquaintance is approaching, walking towards you but on the other side of the street. You try to catch their attention but, rather than wave back, this person carries on walking without acknowledging you, with their head remaining bowed down. Let us suppose the thought then goes through your mind: ‘What have I done to upset them, why doesn’t this person like me?’ These cognitions might naturally cause you to become worried about your relationship with that person and more generally about how others perceive you. You might later also experience some physical symptoms that commonly accompany worry such as difficulty sleeping and restlessness while the matter plays on your mind. Now, let us imagine an alternative cognitive response to the situation. In this instance, you think instead: ‘They seem preoccupied, I wonder what is concerning them?’ This line of thought is likely to have impacted less on your mood because it is enquiring about their situation rather than reflecting negatively on your own. As such, it will probably lead to a different course of action, perhaps contacting the acquaintance to check if they are in any difficulty.

The CBT approach provides a framework for understanding how individuals’ interpretations of events may lead to the development and maintenance of psychological disorders (such as depression and anxiety). CBT treatment then involves the use of techniques to change dysfunctional patterns of cognition and behaviour that are central to such psychological difficulties. This approach emerged in the 1950s and 1960s, both arising out of ‘behavioural approaches’ that were popular at the time and as a reaction to ‘psychoanalytic psychotherapy’. Before investigating CBT further, I first explore these therapeutic approaches to help us to understand its roots.

Psychoanalytic psychotherapy

Psychoanalytic psychotherapy has been in existence for over a century and, over this time, it has developed into numerous models of the mind and human nature. Therefore, you should bear in mind that below is a brief, basic summary of one (the Freudian) model that is informed by Atkinson et al. (1990) and also Smith (1995). The psychoanalytic approach assumes that various tensions or conflicts exist within an individual’s psychological ‘make-up’ or personality. These conflicts arise as a result of competing demands made by three different components that exist in the person’s mind. These are termed: id, ego and super-ego. The id develops earliest in life and consists of our basic impulses, motivations and drives (for example, the need to eat and to gain sensual pleasure). Later, as infants, we learn that these impulses cannot always be satisfied immediately, and we develop another element or aspect to our personality: the ego. This is essentially the manager of the id. It juggles the competing demands of the id, the real world and also the super-ego. The super-ego consists of the values and morals of society that are taught to the child by their parents and other adults. This is the part of the mind that rewards the individual for being good and punishes them for being bad.

Sigmund Freud (1856–1939) was the principal originator of this approach (in the late 19th century). He proposed that some difficulties emerged from tensions or conflicts between these elements. He also pictured the mind as having a similarity to an iceberg. Most of the iceberg is not visible because it is below the water’s surface. Similarly, much of the activity of the human mind occurs below the surface of our consciousness, therefore occurring on an unconscious level. When there is a severe conflict, the ego can protect the individual by pushing it into the unconscious. So, for instance, an anxiety disorder might be fuelled by the presence of unconscious, unacceptable or dangerous impulses that are kept in check (or repressed) because they might impact upon a person’s self-esteem or relationships. However, this is not a permanent solution and this unconscious material exerts pressure. At times this finds expression through irrational behaviour, dreams and possibly psychological difficulties if the ego is unable tosufficiently manage the situation.

Psychoanalysts seek to help their clients by bringing their conflicts into their awareness, ideally transforming symptoms into insights. They attempt to uncover the unconscious conflicts through use of techniques that facilitate their expression. These include:

• free association – unconscious conflicts can be revealed by the client saying what comes into their mind without any conscious editing;
• dream analysis – dreams are considered to contain unconscious desires in a disguised form;
• analysis of ‘transference’ responses – the client’s unconscious feelings towards the therapist mirror childhood responses to parents that can explain the origins of conflicts; and
• interpretation – the client is helped to develop insight by the analyst feeding back or interpreting the understanding that they have learned about the client’s resistance and motivations.

The process of psychoanalysis is lengthy and intense. It traditionally involves therapy sessions for several times a week, for at least a year and often longer. Its protagonists believe that, as unconscious material is brought to light and understood, symptoms are dissipated.

In understanding the historical development of CBT, I draw on Morrey (1995) as well as France and Robson (1997). CBT pioneers such as Albert Ellis (1913–2007) and Aaron Beck (1921–) were originally psychoanalytic psychotherapists who, in the 1950s and 1960s, came to understand that there were radically different ways to make sense of clients’ psychological difficulties. Another key individual is the clinical psychologist, George Kelly (1905–1967). He also developed an approach in 1955 that emphasised certain principles that were common to CBT. I focus below on Beck’s model because historically it has been the most popular form of CBT practised in the UK (Morrey, 1995). However, it needs to be noted that there have been other contemporary CBT approaches that remain popular (for instance, Rational–Emotive Therapy). There have also been important developments in the field of CBT in recent years (such as mindfulness-based CBT).

Beck originally sought to experimentally investigate the psychoanalytic proposition that depression was fuelled by repressed hostility. He did this by surveying the dream content of depressed individuals. His results contradicted this hypothesis and he found that their dreams were characterised by pessimism rather than anger. Likewise, within his therapy sessions, when clients were asked to free associate, the content of thisprocess was not always of relevance to what was hypothesised to be the roots of their difficulties. Rather, their thoughts revolved around more immediate reactions to their situation, such as worrying about how Beck would judge a comment that they had made. Upon further investigation, he found that many depressed clients reportedexperiencing these types of thoughts and that they seemed to occur as much in their everyday lives as in the therapy session. He labelled these as ‘automatic thoughts’ because they occurred rapidly and fleetingly without conscious prompting. While some of the thoughts were plausible, many seemed irrational or without basis, yet at the moment they occurred they were accepted unquestioningly by the client. They were often negative in nature and hence became known as negative automatic thoughts. Beck came to see these patterns of thinking as a distorted lens through which clients saw both themselves and their surroundings. He helped his clients to explore a method of correcting these patterns by challenging these thoughts with questions such as: ‘What is the evidence for … [their interpretation of an issue or situation]?’ and ‘Is there an alternative explanation?’ He found that, as clients used this technique to develop an alternative perspective, their difficulties rapidly improved – these observations forming the early building blocks of CBT (Beck, 1976).

Exercise 1.1 The origins and basics of CBT

Learn about the fundamentals of CBT by watching these internet clips:

• Beck describes the origins of CBT: www.youtube.com/watch?v=g879IJmAQCM&feature=related.
• Beck’s psychologist daughter (Judith) talks about the basics of CBT: www.youtube.com/watch?v=45U1F7cDH5k.
• David Clark (an eminent UK clinical psychologist) explains the principles of CBT in a way that a client can understand: www.youtube.com/watch?v=bvH9kUUmGog.
• A client describes her experience of receiving CBT: www.youtube.com/watch?v=GVX4iVXtT-o&feature=relmfu.

Behaviour therapy

‘Behaviour therapy’ refers to a number of different therapeutic approaches based on the principles of learning, which were established in the early to mid-twentieth century. Learning theory pioneers such as Ivan Pavlov (1849–1936) and Burrhus Skinner (1904–1990) found that animals and humans alike learn in two primary ways. Together, these form the building blocks of learning (Atkinson et al., 1990). The first of these is termed classical conditioning and refers to learning that one event will follow another. For example, a baby learns that milk will follow from the sight of a breast. In his classic experiment, Pavlov retrained a dog’s salivation response. Naturally, when a dog sees food (the food in this context is termed an ‘unconditioned stimulus’), it salivates (an ‘unconditioned response’ to this stimulus because it is a natural one). However, let us suppose a bell (a ‘neutral stimulus’) is also rung each time that the food is presented. Over time, the dog will associate the bell with the food and then salivate to the sound of the bell alone (this then becomes a ‘conditioned response’ to the ‘conditioned stimulus’ – the bell).

The second form of learning is termed operant conditioning and refers to learning that a behaviour will be followed by a consequence. For example, a child learns that hitting a sibling will result in disapproval from a parent. Skinner found that, if an animal is given a reward (such as food) after performing a behaviour (like pressing a lever), the frequency of that behaviour increases dramatically. In this way, rewards (or ‘reinforcements’) increase the rate of behaviour occurrence. There are two types of reinforcement: positive and negative. Positive reinforcement occurs when a behaviour increases or is strengthened following the provision of a satisfying stimulus. So, a person might work harder or take on more duties if they are paid more. Negative reinforcement occurs when a behaviour increases or is strengthened as the result of taking away an unpleasant stimulus. In this way, a person might learn to improve poor work performance in order to avoid disapproval from their manager or take aspirin to remove a headache. Punishment differs from reinforcement in that it consists of providing an unpleasant stimulus after a behaviour (for example, slapping a child for throwing some food). This will tend to suppress the behaviour. However, as punishment fails to convey an appropriate alternative behaviour, its effects can be unpredictable. In addition, it can instil fear and aggression, and so for these reasons it is seen as a less effective form of learning. Later, psychologists also identified learning that occurs through observing others (Bandura, 1973).

Aspects of the development and maintenance of clinical difficulties can be understood in terms of learning theory. For example, a phobia might be developed through classical conditioning. This was demonstrated by John Watson (1878–1958) when he introduced a nine-month-old baby (Little Albert) to a number of objects (including a rat). Initially, Albert did not exhibit fear in response to these. However, as Albert was subsequently introduced to these objects, a loud and frightening sound was made. Consequently, Albert made a link between the conditioned stimulus (the rat) and the conditioned response (fear), illustrating a mechanism for the development of a phobia. Clients sometimes report similar origins to their own phobias. A phobia of public transport might develop after experiencing an extremely humiliating experience on a bus such as involuntary defecation. Fear may then be maintained by operant conditioning as the avoidance of aversive states is reinforced through avoidance of the feared stimulus (Mowrer, 1947). This can be illustrated with the example given above where, by avoiding public transport, the person does not experience the high anxiety associated with this situation. This encourages them to continue to avoid public transport in the future.

Exercise 1.2 The application of learning theory

A mother is travelling on a bus with her 4-year-old son. The son has a temper tantrum because he is bored and wants to go home to play with his toys. The mother, feeling embarrassed, removes her son from the bus, abandons her trip and takes him home. Which behaviour is being reinforced? What form of reinforcement is being used?

When the mother and child get home, the child quietly plays with his toys. At this point, the mother shouts at her son for embarrassing her earlier. Despite the mother’s intentions, which behaviour is actually being punished at that point?

Is the mother’s behaviour helping the child? If not, give some thought to what responses would be more helpful for him.

Behaviour therapy uses the principles of learning theory in order to help people to overcome their psychological problems. For instance, the treatment of phobias involves a process of deconditioning. This approach was termed ‘systematic desensitisation’ (Wolpe, 1969) an...

Table of contents

• Cover
• Half Title
• Publisher Note
• Title Page
• Copyright Page
• Contents
• Illustration List
• Table List
• Sidebar List
• About the editors and contributors
• Acknowledgements
• 1 Introduction
• 2 The role of the LICBT practitioner
• 3 Understanding the problem
• 4 The therapeutic relationship
• 5 Interview structure
• 6 Assessment and management of risk
• 7 Behaviour change and client engagement
• 8 Understanding depression
• 9 Understanding anxiety
• 10 Treatment strategies
• 11 Inclusive values and perspectives
• 12 Inclusive practice
• 13 Working with older people
• 14 Working with long-term conditions
• 15 Adapting LICBT for people with learning disabilities
• 16 Work and wellbeing
• 17 Supervision
• Appendix The use of case studies
• References
• Index