Week 8 lecture - IAPT and CBT

Question 1

what is IAPT

Answer 1

• Services which provide evidence-based psychological therapies to people with anxiety disorders and depression.

Question 2

who is IAPT for?

Answer 2

• For adults aged 18 years and over, who are experiencing mild to moderate psychological difficulties.

Question 3

stepped care model

Answer 3

• Supports patients, carers and practitioners in identifying and accessing the most effective interventions
  
  • Step 1 - primary care/gp
  • Step 2 - psychological wellbeing practitioners
  • Step 3 - CBT therapists/high intensity therapists
  • Step 4 - senior CBT therapists/counselling psychologists

Question 4

features of IAPT new approach

Answer 4

• Evidence based
  
  • Community settings
  • Choice of venues
  • Quick access and treatment
  • Self-referral
  • Psychoeducation
  • Guided self-help
  • Use of technology (telephone and internet)

Question 5

what do therapies for anxiety and depression involve?

Answer 5

• NHS talking therapies
  ○ 1-1 in person, over the phone, through video consultation, in a group
  
  • Practical exercises and tasks both in and outside of the schedules sessions, e.g. using self-help workbook

Question 6

therapies in IAPT

Answer 6

• Depression:
  ○ Guided self-help based on cognitive behavioural therapy principles
  
  • Anxiety:
    ○ Guided self-help based on cognitive behavioural therapy principles. This is not advised for social anxiety disorder or post-traumatic stress disorder
  • Post-traumatic stress disorder:
    ○ Trauma focused Cognitive behavioural therapy (Tf CBT)
  • Social anxiety disorder:
    ○ Cognitive behavioural therapy (CBT)

Question 7

common myths about cbt

Answer 7

1. The therapeutic relationship is not important in CBT, because it’s just about applying technique X to problem Y.
   
   2. CBT is about positive thinking.
   3. CBT doesn’t deal with the past.
   4. CBT is not interested in the unconscious.
   5. CBT is quick to learn and easy to practise.

Question 8

7 principles of CBT
(Kennerley, Kirk & Westbrook, 2017)

Answer 8

1. The cognitive principle
   - It is the beliefs about events and situations and not the events or situations themselves that are important
   
   2. The behavioural principle
      
      • What we do has a strong influence on what we think and how we feel
   3. The continuum principle
      
      • Our experiences are all on a continuum and mental health difficulties are at the extreme ends of the continuum
   4. The here-and-now principle
      
      • CBT focusses more on current experiences and problems instead of those of the past
   5. The interacting systems principle
      
      • Problems can be viewed as interactions between thoughts, feelings, body changes and behaviour based in our environments
   6. The empirical principle
      
      • CBT theory and the applied therapy benefits from on-going evaluation
   7. The interpersonal principle
      
      • CBT is a working alliance between patient and therapist

Question 9

3 levels of cognition: Adapted from Kennerley, Kirk & Westbrook, (2017)

Answer 9

core beliefs –> underlying assumptions –> automaitc thoughts

general to specific
less accessible to accessible
harder to change to easier to change

Question 10

NATs

Answer 10

negative automatic thoughts
Beck

negatively felt appraisals
more prevalent when under pressure and when a sig. event has occured
anyone can experience them

Question 11

automatic thoughts/NATs

Answer 11

• These thoughts influence our affect (emotions);
  - An experience in any of the four areas has an impact on the remaining areas.
  
  • Common features of automatic thoughts include
    
    • They happen without effort
    • They can easily become conscious
    • They can become habitual so we do not notice them without paying attention to them as we experienced in the exercise
    • They can be mental images as well as thoughts

Question 12

core beliefs

Answer 12

• Person’s fundamental beliefs about themselves, other people and the world;
  
  • Common features:
    
    • They are usually learned early in life as a result of childhood experiences*
      § *Although they can develop and change later in life for example in response to adult trauma
    • They are usually not immediately accessible in our consciousness;

Question 13

underlying assumptions

Answer 13

• Underlying assumptions (UAs) bridge the gap between Core Beliefs and Automatic thoughts;
  
  • They often develop in response to the core beliefs;
  • They are usually conditional statements including
    
    • If….then…./ should/ must/ otherwise
  • They can become ‘rules for living’ developed from experience and the presence of the core beliefs;
  • They can be a person’s strategy for living with the core belief and if this is negative then they can become dysfunctional;
  • Dysfunctional assumptions are rigid; over-generalised; inflexible and illogical when reviewed in an objective way;

Question 14

cognitive distortions

Answer 14

• Unhelpful thinking patterns;
  
  • May come as a result of difficult life experiences or be learnt;
  • May sound “rational” on the surface, but are usually incorrect and inaccurate when examined more closely;

Question 15

common cognitive distortions

Answer 15

1. All or nothing thinking;
   
   2. Overgeneralisation;
   3. Negative mental filter;
   4. Catastrophising;
   5. Should statements
   6. Self-worth;

Question 16

ABC model

Answer 16

• A tool to identify cognitive distortions;
  
  • Activating event (trigger) →Belief →Consequences

Question 17

process of CBT

Answer 17

1. CBT assessment identifies the cognitions that people have and how their responses to those cognitions can maintain their problem experiences;
   
   2. CBT formulation is the development of a shared understanding between therapist and patient of the problems being discussed;
   3. CBT intervention is the method of supporting a person to learn new ways of thinking or behaving to reduce problems;
   4. CBT evaluation occurs throughout the intervention and is a way of monitoring the progress on individualised treatment goals;

Question 18

key strategies/tools in CBT

Answer 18

• Agenda setting
  
  • Goal setting
  • Identifying activating events
  • Negative Automatic Thoughts
    
    • NATS
  • Maintenance cycles
    
    • Vicious cycles
  • Core beliefs
  • Guided Discovery/ Socratic questions
  • Cognitive challenging
  • Cognitive restructuring
  • Psychoeducation
  • Homework
  • Thought diaries
  • Mood monitoring
  • Fact vs Opinion
  • Behavioural experiments

Question 19

socratic method

Answer 19

• Socratic questioning allows the therapist and the client to explore what the clients already know and what they have not considered yet, or have forgotten;
  
  • Clients are encouraged to discover alternative views and solutions for themselves;
  • Can be helpful in clarifying the meaning of problems and in order to re-evaluate previous conclusions;

Question 20

cognitive techniques

Answer 20

• Identifying cognitions – diary keeping
  - Situation – Feelings (+ level of discomfort) – Thoughts
  
  • Enhancing recall through imagery and role play
  • Clarifying global statements (e.g., “In what way useless?);

Question 21

physical techniques

Answer 21

• Relaxation
  - To help with physical tension (anxiety, depression)
  
  • Controlled breathing
    
    • Hyperventilation as one of the benign symptoms of panic attacks
  • Physical exercise
    
    • NICE recommends that all patients with mild depression should be advised on the benefits of structured exercise programme (NICE, 2004a);

Question 22

CBT case formulation

Answer 22

• A provisional map of a person’s presenting problems that describes the territory of the problems and explains the processes that caused and maintain the problems (Bieling & Kuyken, 2003)
  
  • Properties:
    
    • Describes and explains presenting problems in terms that can be operationalised
      (cognition, affect, and behaviour)
    • Is reliable and valid
    • Provides guidance for intervention
    • Is an active and ongoing process, responsive to new date
  • Elements:
    
    • Description of presenting problems (in clear, specific and measurable terms)
    • Developmental history
    • Causal factors
    • Maintaining factors
    • Guides for intervention

Question 23

aims of CBT for chronic pain (CBT-CP)

Answer 23

• Reduce the negative impact of pain on daily life
  
  • Improve physical and emotional functioning
  • Increase effective coping skills for managing pain
  • Reduce pain intensity

Question 24

modes of assessment

Answer 24

• Semi-structured/ structured interviews
  
  • Psychometric rating scales
  • Self-monitoring
  • Observations (in session or via home work tasks)
  • File reviews from previous professional documentation

Question 25

Case formulation: 5 P’s model (Weerasekera, 1993)

Answer 25

presenting problem
precipitating (triggering) factors
perpetuating (maintaining) factors
predisposing (underlying) factors
protective factors

Question 26

intervention for CBT-CP

Answer 26

• Typical intervention is session 4-10
  
  • Interventions in CBT-CP include
    
    • Goal-Setting
    • Use of exercise
    • Relaxation training
    • Pleasant activities
    • Cognitive strategies
    • Sleep interventions
  • A treatment plan for Steve based on his formulation may include:
    
    • Cognitive strategies to explore the ideas that he must take pain killers to do his job; or that he is useless if he is unable to do his job;
    • Skill development for managing pain:
      § Relaxation skills; mindfulness; pacing; exercise
  • Behavioural experiments to challenge himself to see what the impact is of not misusing prescription medication and recording this on diary sheets as homework;
  • Supporting him to develop alternative role investments and engage in activities that he
    previously enjoyed;

Question 27

Evaluation and anticipated outcomes for CBT-CP

Answer 27

• Typically sessions 11-12
  
  • Review therapy goals which should be SMART
  • Regular self-monitoring of pain experiences
  • Regular self-monitoring of prescription medication use and alcohol consumption
  • Increased use of adaptive coping skills and strategies
  • Anticipated reduction in pain experiences and use of substances for managing symptoms
  • Development of a Relapse Prevention plan or Wellness and Recovery Action Plan (WRAP: Copeland, 2002)