Cognitive Behavioural Therapy in Mental Health Care

Alec Grant, Michael Townend, Ronan Mulhern, Nigel Short

• Publisher: SAGE Publications Ltd
• Year: 2010
• Print ISBN: 9781847876065, 9781847876058
• eBook ISBN: 9781446241783
• Edition: 2
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

This second edition provides an accessible and thorough overview of the practice of CBT within mental health care. Updates and additions include:

- Revised chapters on the therapeutic relationship and case formulation

- New material on personality disorders and bipolar disorder

- New material on working with diversity

- Content on the multidisciplinary context of CBT, the service user perspective, CBT from a holistic perspective

- Developments within the cognitive behavioural psychotherapies

- Continous professional development for the CBT practitioner

- Photocopiable worksheets linked to case studies.

Already a tried-and-tested guide for trainee psychologists and psychotherapists, as well as clinicians in mental health services and private practices, this text is also of value to practitioners who need refresher courses in CBT.

1

INTRODUCTION

Alec Grant, Michael Townend, Ronan Mulhern and Nigel Short

This text is greatly different from its first edition in 2004, in its scope, range, subject matter, number of authors and theoretical and empirical advancement.The 2004 edition was of its time; apart from some discussion on the therapeutic alliance and case formulation, organisational problems which might potentially impede the uptake of a cognitive behavioural (CB) approach, and a critique of some of the assumptions underpinning CBT practice, the focus of the last edition was mainly on working with a range of clinical problems using standard CBT. Little account was given to cultural diversity or plurality, and no account was accorded to age-related issues. Equally, no acknowledgement was given to the blooming and burgeoning face of CBT in a variety of contexts.

This second edition attempts to remedy all of the above deficits, and gives greater, more contemporary and sophisticated detail in three sections: Part One: Fundamentals; Part Two: Disorders; Part Three: Contextual Issues and Challenges. Each of these parts utilises and discusses diverse empirical and theoretical work which would not have been possible five years ago.The chapters are written by experts in their fields, who are all either researchers, teachers, clinicians or supervisors within the CBT field.

The sections of the book, and the chapters within them, will now be briefly described.

PART ONE: FUNDAMENTALS

• Chapter 2 The Therapeutic Relationship. A balance needs to be struck between relational and technical factors. There is a need to know what makes the relationship work, how to start, maintain and finish it, and deal with problems that arise in it. For almost 20 years now there has been an increased interest in the nature of the therapeutic relationship within CBT. Grant and Townend describe this, look in detail at threats to the therapeutic alliance, and explore what makes the therapeutic relationship work in CBT.
• Chapter 3 Case Formulation. In this chapter, Grant and Townend argue that gathering information around client meaning-making is neverending in the process of the development of a case formulation. They describe and evaluate basic and advanced models of formulation, and distinguish between generic, problem-specific and idiosyncratic formulation models and the importance of ‘shoulder to shoulder’ sharing of these with clients. They look at the practicalities and process of formulation development and key issues, including the evidence base underpinning the case formulation concept in CBT.
• Chapter 4 Assessment, Therapy Structure and Management of the Psychotherapy Process. In Chapter 4, Townend and Grant thoroughly discuss the place, relevance and relationship of classification systems in CBT practice. To this end, they evaluate the distinctive nature and interaction between nomothetic (related to general populations) and idiographic (related to specific individuals) approaches within CBT assessment. They also explore the overall aims of assessment from the perspectives of both client and therapist, and the strategies and approaches to assessment utilised in CBT. They finally discuss the management of the assessment process so as to motivate and instil optimism and the potential for change in clients.

PART TWO: DISORDERS

• Chapter 5 Depression. In this chapter, Mulhern identifies the nature and classification of depression from a diagnostic viewpoint. He then goes on to describe the main features of Beck’s cognitive model of depression, describing the main issues involved in its assessment and formulation. After exploring the major cognitive and behavioural interventions for depression, he explores and clarifies the role of metacognition in its therapeutic management.
• Chapter 6 Anxiety. In Chapter 6, Short describes anxiety from a CBT perspective, outlines the role of behaviour in maintaining anxiety difficulties and describes some key theoretical explanations of anxiety. Important strategies and principles involved in begininning work with anxiety sufferers are described, including fostering hope for positive change. The ways in which individuals’ fearful predictions serve to maintain anxiety are explained in relation to the principles behind exposure therapy and the notion of ‘fear of fear’. The role of avoidance in maintaining anxiety difficulties is discussed, as is the importance of behaviour experiments in helping individuals with anxiety difficulties recover.
• Chapter 7 Antisocial and Borderline Personality Disorder. In this chapter, Davidson, Sharp and Halford argue that psychological treatments have proved much more promising than pharmacological treatments in the treatment of personality disorders. They outline the diagnostic characteristics of borderline and antisocial personality disorders and describe a specific cognitive model of personality disorder. The general principles of CB treatment are discussed, through formulation proceeding from childhood and development for both borderline and antisocial personality disorders. They describe the overdeveloped behavioural patterns and maladaptive core beliefs characteristic of borderline and antisocial personality disorders. They also outline the role of the therapeutic relationship for both disorders. Finally, using case examples, they illustrate CBT in therapeutic practice for borderline and antisocial personality disorders.
• Chapter 8 Psychosis. In Chapter 8, Mulhern describes the emergence of CB theories of psychosis, voice hearing and unusual beliefs, including CB understandings of ‘negative symptoms’ of psychosis. He outlines CB assessment for psychosis and voice hearing, in relation to both CB functional analysis and case formulation. He articulates the principles underpinning assessing unhelpful or unusual thoughts and beliefs, describing the principles and specifics of CB interventions for voice hearing and unusual thoughts on the basis of case vignettes. Finally, he describes the relationship between substance abuse and psychosis and outlines the principles behind recovery and relapse prevention.
• Chapter 9 Bipolar Disorder. In this chapter, Mansell recognises clients for whom mood swings are their main concern. He articulates the main components of an Integrative Cognitive Model of mood swings and bipolar disorders. The relationship between formulation-driven models and fundamental theories of psychological functioning, specifically Perceptual Control Theory, is explained, as are the importance of conflicting beliefs and control strategies in clients with mood swings and/or bipolar disorders. The above is illustrated by the formulation of a client with mood swings, including the selection of CBT techniques for intervention.

PART THREE: CONTEXTUAL ISSUES AND CHALLENGES

• Chapter 10 Providing CBT in Different Work Settings. In this chapter, Curran, Houghton and Grant argue how the traditional model of CBT delivery has become more difficult to sustain over the years. The main reason for this situation it is argued is that the demand for CBT has increased while the training of additional therapists has not kept up with exponential demand. Briefer forms of CB interventions that have developed are explored and described, as are the different geographical, clinical and policy contextual settings related to non-traditionl CBT delivery. An argument is made for the different levels of training, education and clinical supervision necessary for the application of CBT. These range from simple to complex clinical problems and settings. The need for therapists to demonstrate greater awareness of the organisational contextual factors at play in implementing CBT practice is also considered.
• Chapter 11 Working with Diversity. Levinson’s coverage in this chapter includes the need for greater cultural and diversity awareness among CB therapists. She addresses the role of racism and disadvantage in diversity and the tensions between culturally supported and empirically supported therapies. She examines feminist critiques of mental health and the important role of small voluntary organisations. The specific relationship between CBT and diversity is explored, as is the role of an ethic of social justice within the field.
• Chapter 12 CBT for Children and Adolescents. In this chapter, Levinson identifies the diverse nature of the client group in the speciality of CBT for children and adolescents, while exploring the CBT evidence base for working with young people. She stresses the need for a more holistic, socially and politically aware assessment when working with this client group and articulates some of the key debates in such work. Finally, she demonstrates holistic formulations to illustrate her argument.
• Chapter 13 CBT for Older People. Rogers argues how demographic and other changes will increase demand on providers of psychotherapy for older people. He articulates some of the most popular suggestions for modification of CBT when working with this population, and recognises the effect of the ‘loss-deficit’ model on older people’s CBT. He acknowledges the impact of therapists’ cognitive and behavioural, covert and overt, contribution to working with older people, and the importance of clinical supervision in this context. Recognising how elements of the therapists’ own professional, social and cognitive development may influence therapy, he strives towards a better understanding of the importance of case formulation and the value of reflective practice in CBT with older people.
• Chapter 14 The Service User Perspective in CBT. In this chapter, Grant and Townend consider the role that service user involvement has had within the CBT field, and discuss why service users should be involved in CBT delivery. Good practice in the area of service user involvement at a number of levels of practice is identified, as are areas identified for future development in this important emergent field, from service user involvement in policy development to their involvement in the therapeutic and teaching processes.
• Chapter 15 CBT from a Holistic Perspective. Grant in this chapter discusses some of the controversies surrounding the concept of ‘recovery’ in mental health, and considers the implications of the recovery movement in mental health for the practice of CBT. The relationship between hope, social support and recovery in mental health and the implications for CB practice are explored, as are the links between the concept of recovery and practice and outcome in CBT. Some consideration is given to the role of the use of therapist power in the CB therapeutic relationship, while attempts are made to understand the role of the therapeutic relationship in relation to both client and therapist attachment styles and the development of compassionate CB practice.
• Chapter 16 Developments within the Cognitive Behavioural Psychotherapies. Curran, Houghton and Grant recognise within this chapter that there is a diversity of approaches that come under the heading ‘CBT’, and that these relate to the evolution and development of the cognitive behavioural psychotherapies. They argue that these approaches often have different philosophical and theoretical underpinnings. They appreciate the role of transdiagnostic approaches within this contested arena. They seek to demonstrate the contribution of cognitive science, empirical support and clinical issues in the development of the CBTs. Finally, they argue that the different approaches to CB therapy, which have emerged in recent years, place difficulties on assumptions for a unified approach called ‘CBT’.
• Chapter 17 Current Issues in CBT Supervision. In this chapter, Grant and Townend outline the ways in which clinical supervision in CBT overlaps with therapy and teaching. These are contextualised within the main empirical findings from the survey conducted by Townend et al. (2002). CBT supervision is contex-tualised with supervision in mental health more broadly. Contemporary educational approaches to CB supervision are articulated and the implications of the IAPT agenda for the development of supervision competencies in CBT are argued. Finally, the problem of non-disclosure and its implications in CB supervision is discussed.
• Chapter 18 The Evidence Base and Philosophical Debates in CBT. In this final chapter, the term ‘paradigm’ is explained, and it is argued that different sets of paradigmatic assumptions relate to the histories of modernism and postmodernism. Some of the reasons behind the problem of inter-paradigm communication are explored, as is the value of alternative forms of writing other than that governed by the medical model. The historical basis for the emergence of autoethnography in the social sciences, and its main characteristics, is explored. The increased publication of autoethnographic texts, and how this may benefit the dominant research agenda, the CB scientific community, therapists and clients, and the public at large, is explored. Finally, the possible objections that may be raised about autoethnography, from within the CB community, are discussed.

FINAL ISSUES

The content and form of this new text were informed largely by reviewer feedback in 2007. It is to be hoped that the finished ‘product’ will not only inform readers, but also stretch their perspectives on CBT in lots of different ways. While we, the editors, hope this to be the case, the final judgement rests with the readers. Editing and writing this text has been no simple task. No doubt we will have met the needs of many readers, while frustrating others. That said, the editors of the book are very proud of this finished product and pleased to be associated with the progressive developments in CBT that are discussed, debated and represented within it.

PART ONE

FUNDAMENTALS

2

THE THERAPEUTIC RELATIONSHIP

Alec Grant and Michael Townend

LEARNING OBJECTIVES

After reading this chapter and completing the activities at the end of it you should be able to:

1. Evaluate the balance in CBT practice between relationship and technical factors.
2. Consider the relevance to your own practice of the issues of validation resistance, emotional philosophies, victim resistance, schematic resistance, schematic mismatch, sunk-cost commitment and self-handicapping.
3. Conceptualise the therapeutic relationship in terms of what makes it work, establishing it in the first place, developing collaborative frameworks, developing and maintaining the relationship, and overcoming relationship ruptures.

A good relationship between client and therapist is, at the very least, considered to be the base from which all therapeutic work takes place. (Hardy et al., 2007: 24)

INTRODUCTION/BACKGROUND

For almost 20 years there has been an increased interest in the nature of the therapeutic relationship in CBT (see e.g. Bennett-Levy andThwaites, 2007; Gilbert, 1992; Gilbert and Leahy, 2007; Leahy, 2001; Safran, 1998).There is also some empirical support for the proposition that the client’s perception of the quality of the relationship is related to outcome (Martin et al., 2000; Orlinsky et al., 2004), with early alliance predictive of later outcome (Gaston et al., 1991). It seems to be the case...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• 1 Introduction
• Part One Fundamentals
• Part Two Disorders
• Part Three Contextual Issues And Challenges
• Reference
• Index