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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
There is a growing awareness of the need to address the psychological distress associated with physical ill health; however, current resources are limited and difficult to access. The best way to tackle the issue is by enhancing the skills of those professionals who have routine contact with them. CBT provides the evidence-based skills that most readily meet these requirements in a time and cost efficient manner. Based on materials prepared for a Cancer Network sponsored training programme and modified to address the needs of a larger client population of people experiencing psychological distress due to physical ill-health, this innovative workbook offers a basic introduction and guide to enable healthcare professionals to build an understanding of the relevance and application of CBT methods in everyday clinical practice.
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Veröffentlichungsjahr: 2013
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Contents
About the Authors
Acknowledgements
Introduction
Part I The Workbook: The Cognitive Behavioural Approach
Chapter 1 What is the Cognitive Behavioural Approach?
Chapter 2 The Relevance of a Cognitive Behavioural Approach for People with a Life-changing Illness
Chapter 3 Does Cognitive Behaviour Therapy Work? The Evidence Base
Chapter 4 Communication Skills in Health Care
Chapter 5 Cognitive Behavioural Communication Style
Chapter 6 Guided Discovery: Using the Socratic Method
Chapter 7 Assessment
Chapter 8 Formulation
Chapter 9 Deciding on a Course of Action: Part 1
Chapter 10 Goal Setting and the Step-by-Step Process
Chapter 11 The Practicalities of Setting Goals
Chapter 12 Bringing About Change
Chapter 13 Methods of Behaviour Change
Chapter 14 Methods of Cognitive Change
Chapter 15 Challenging Unhelpful Thoughts
Chapter 16 Managing Emotions and Unpleasant Physical Sensations
Chapter 17 Decision on a Course of Action: Part 2
Chapter 18 Applying a Cognitive Behavioural Approach to Clinical Practice
Part II The Issues: Some Psychological Problems
Adjustment difficulties
Altered body image
Anger
Avoidance
Denial
Fatigue
Fear of the future
Inactivity
Indecisiveness
Intrusive/distressing thoughts
Lack of motivation
Loss of pleasure or ability to enjoy things
Low mood
Low self-esteem
Negative outlook
Pain
Panic attacks
Safety behaviours
Physical tension
Poor concentration
Problem solving difficulties
Setbacks
Sleep difficulties
Unassertiveness
Worrying
Part III The Toolkit: CBT Methods in Practice
Section 1 TECHNIQUES
Activity Monitoring
Assertiveness Skills
Assessing psychological distress
Attention Strategies
Basic Counselling Skills
Behavioural Change Methods: A Summary
Behavioural Experiments
Behavioural rehearsal
Believable Alternative Thoughts
Breathing Control
Challenging Unhelpful Thoughts
Cognitive Change Methods: A Summary
Denial: Strategies for Encouraging Acceptance
Denial: Strategies for Engaging the Patient
Denial: Strategies for Reducing Distressing Thoughts
Denial: Suggestions for Questions to Ask
Effective Communication Skills
Emotional Expression
Expressive Writing
Graded Activities
Listening Skills
Mental Distraction
Mindfulness
Pacing
Problem Solving
Psycho-education
Purposeful Planning
Relaxation Exercises
Respectfulness Skills
Socratic Questioning
Stimulus Control
Weighing the Pros and Cons
Section 2 INFORMATION SHEETS
Antidotes to Bad Days
Assertiveness Rights
Assertiveness Techniques
Bad Old Habits: Avoiding Relapsing Into Them
Change: Bringing It About
Change: The Desire for It
Change: The Transition Curve
Coping with Setbacks 1: Physical Health Setbacks
Coping with Setbacks 2: Mental Attitude Setbacks
Denial: Advantages and Disadvantages
Experiential Learning Cycle
Goal Setting and the Step-by-Step Approach
Goal Setting: Examples
Goal Setting Questions
Mental Traps: Examining the Evidence
Mental Traps: Examples of How to Get Out of Them
Mindfulness Attitudes
Mindfulness Exercises
Pacing
Pacing Examples
The Reactions of Other People
Reflective Practice Diary Guidance
Relaxation: Mental Exercise
Relaxation: Muscle Exercise
Relaxed Breathing Exercise
The Serenity Prayer
Sharing and Mixing with Other People
SMART Guidelines
Socratic Questioning: Examples
Stress: The Effect it Has
The Stress Response
A Vicious Cycle Model of Anxious Avoidance
A Vicious Cycle Model of Anxious Preoccupation
A Vicious Cycle Model of Hopelessness-Helplessness
Section 3 RECORD FORMS
Event-Emotion-Thought Analysis Form
Example of Event-Emotion-Thought Analysis Form
Believable Alternatives
Thought Record
Pacing Record Form
Denial: Assessing its Costs and Benefits
Denial: Example of Pros and Cons Assessment
Action Plan for Denial
Goal Planning: Step-By-Step Action Plan
Your Ideas for Goals
Reflective Practice Diary
References
Index
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Library of Congress Cataloging-in-Publication Data
CBT for chronic illness and palliative care : a workbook and toolkit / Nigel Sage … [et al.].
p. cm.
Includes bibliographical references and index.
ISBN 978-0-470-51707-9 (pbk. : alk. paper)
1. Chronic diseases–Psychological aspects. 2. Palliative treatment–Psychological aspects.
3. Chronically ill–Rehabilitation. 4. Cognitive therapy. I. Sage, Nigel.
RC108.C38 2008
616’.044–dc22
2007044558
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
ISBN 978-0-470-051707-9
About the Authors
Nigel Sage is Consultant Clinical Psychologist in Cancer and Palliative Care at The Beacon Community Specialist Centre for Cancer and Palliative Care in Guildford, Surrey. He is an Accredited Cognitive Behaviour Therapist and also works in primary care mental health in Hampshire.
Michelle Sowden is Consultant Clinical Psychologist at Frimley Park Hospital where she has provided and developed a service to patients with physical health problems across the Clinical Directorates. She has a special interest in the application of cognitive behavioural and systemic therapies to the management of chronic medical conditions.
Elizabeth Chorlton is a Chartered Clinical Psychologist working at Frimley Park Hospital, in the Department of Psychological Medicine, with patients who are experiencing psychological difficulties as a result of physical health problems. In addition to her clinical psychology training, she has an MSc in the field of health psychology.
Andrea Edeleanu is Director of Specialist Therapies and Service User Involvement for Surrey and Borders Partnership NHS Trust. She works clinically in Community Health Psychology and provides consultancy and clinical supervision to colleagues in health, mental health and community services. She is a Consultant Clinical Psychologist, Chartered Health Psychologist and an Accredited Cognitive Behaviour Therapist.
Acknowledgements
This book grew from material prepared originally for a training project for staff working in either palliative care or with cancer patients in other settings. The authors gratefully acknowledge the vital contribution of Surrey, West Sussex and Hampshire (SWSH) Cancer Network, in sponsoring that training project.
We would also like to acknowledge the enormous influence on the content and structure of this book of Drs Stirling Moorey and Kathryn Mannix. Stirling has done so much to establish the role of Cognitive Behaviour Therapy (CBT) in the fields of oncology and palliative care that it is rapidly becoming a service requirement and many health professionals are now seeking some training. For us, his work at St Christopher’s Hospice has been especially important because, along with the training project in Newcastle led by Kathryn Mannix, it has shown that staff with no background in mental health work can acquire and use cognitive behavioural skills. This has provided the inspiration for our own training programme and ultimately this book. Kathryn has also offered us encouragement and practical guidance with our training project for which we are very appreciative.
Grateful thanks are extended to Joanne Coombs for her help in preparing the chapter on the effectiveness of CBT to Ann Hatch, whose experience and skills as a physiotherapist have influenced numerous items included and to Maralyn Sage for her tireless work and patience with both the book and the training project that preceded it. A special thank you is also due to all the participants from our training courses who have taken the trouble to provide constructive feedback and persuaded us to publish. Their suggestions have enabled us to revise our course materials and make this a better book. In this regard a particular mention must be made of Maureen Adam and Susan Kobler who in dual roles as participants and seminar supervisors regularly provided ideas for improvements.
Finally, we wish to express our debt of gratitude to all the patients who, by sharing their experiences with us, have spurred us on to write this. We hope that the resulting book contributes to more people getting more help sooner.
Introduction
CBT in Chronic Illness and Palliative Care: A Workbook and Toolkit is divided into three parts and is intended to give the reader grounding in the principles and techniques of Cognitive Behavioural Therapy (CBT). Ideally, it should be used in junction with a taught course on the use of CBT with people who have life-changing illness or are terminally ill. The course will offer the opportunity to discuss working with these patients and the people close to them. It will give the student the chance to practice the skills they are learning through role-plays and small group exercises; and it will provide time for going back over material that has been difficult to understand or has been misunderstood.
However, such courses are rare, so the book has been written with the expectation that many readers will be learning these skills without the benefit of a supportive course. With this in mind, there are a number of exercises included that have been adapted from the courses we have run and we would ask you to follow these through very carefully if you intend to apply CBT skills in your clinical practice.
Part 1: The Workbook examines important issues and themes that need to be understood and considered by clinical practitioners as well as the basic principles of the cognitive behavioural approach. These range from wider aspects of behaviour change through to the specifics of assessing psychological needs. This material, together with key reference books and supplemented by the exercises at the end of each chapter represent the knowledge base for these core skills when applied to people with life-changing illness.
In Part 2: The Issues some psychological problems, obstacles and needs are referred to as “Problems”. Relevant techniques and sample tactics are identified, providing an idea of how these CBT methods are applied in practice with each problem. Issues about implementing these procedures are covered in “Notes”. Although not written in chapter format, close familiarity with the contents of this part of the book is extremely important.
Inevitably the selection of sample problems is far from comprehensive but the range is sufficiently wide to illustrate the scope of CBT usage. Consequently, when considering applying CBT methods, this part of the book should be consulted first. The intention is to give enough material for you to be able to:
assess the problem or need
indicate the typical cognitive-behavioural approach to coping
where relevant include educational material that can be copied and passed to patients, carers or others
assess improvement and need reduction.
Part 3: The Toolkit provides information on CBT methods in practice that may be of practical assistance when you are seeking to offer some help. There are plenty of different ideas for managing challenging psychological situations in the CBT literature and so, like the list of problems and needs, the suggestions for methods of helping included in this book could not claim to be exhaustive.
Part 3 is divided into three sections.
A fuller description of how to implement each CBT technique is provided in Section 1: Techniques.
Section 2: Information sheets includes further detailed guidance and information sheets which may be copied and used to assist in the CBT.
Section 3: Record forms provides methods for recording events, thoughts and plans in conjunction with the CBT techniques. These forms may also be photocopied.
A4 versions of all information sheets and record forms can be downloaded from the website free of charge and without copyright restrictions by owners of this book, for their own clinical use only.
PowerPoint slides for personal training are also available to view at the website.
PART I
The Workbook: The Cognitive Behavioural Approach
Chapter 1
What is the Cognitive Behavioural Approach?
Cognitive Behaviour Therapy (CBT) has been described by the pioneer of this therapy as:
An active, directive, time-limited, structured approach.
(Beck et al., 1979)
The therapy works by helping patients to:
Recognise patterns of distorted thinking and dysfunctional behaviour. Systematic discussion and carefully structured behavioural assignments are then used to help patients evaluate and modify both their distorted thoughts and their dysfunctional behaviours.
(Hawton et al., 1989)
With the cognitive behavioural approach there is recognition of the way in which all our responses are part of a complicated interplay of actions and reactions. In physics we accept the general law that every action produces a reaction. What is not always so well appreciated is that this applies in psychology too.
We are generally aware that our actions have effects on those around us as theirs do on us. The simple act of smiling at someone when they look at you will produce a reaction in that person. Perhaps they will smile back, treating it as a simple greeting; alternatively, they may interpret it as an invitation to come over and chat; under other circumstances their reaction may be one of anxiety or hostility, if they think you are laughing at them. What ever it is your action will produce a reaction, and that reaction, in turn will have an effect on you. Even a “non-reaction” (such as no glimmer of acknowledgement that you smiled) will carry meaning and provoke a specific reaction in you.
So our social environment affects our behaviour and our behaviour affects our social environment. To a greater or lesser extent the same is true for our physical and economic environments. We can influence (if not control) our comfort, wellbeing, affluence and future prospects. Our comfort, wellbeing, affluence and future prospects similarly can and do influence how we think, feel and behave.
From the cognitive behavioural perspective, however, it is the loops of cause and effect within ourselves that are of special interest. When I put my hand too close to the fire, the outside world (external environment) of intense heat sends signals of pain to my body’s sensory receptors. From that point forward there are a series of reactions and interactions relating to my internal environment. The physical sensation of painful heat triggers emotional responses of intense dislike and thoughts of dangers to be avoided. But the most important and immediate reaction is a behavioural response of withdrawing my hand from the heat. Once this behaviour has happened, I experience a relief of the pain, my thoughts turn to labelling the hot object as something to be avoided or treated warily and it has acquired a negative emotional association.
So, in this example physical sensation has evoked a specific behaviour, reappraising thoughts, and an unpleasant emotional reaction. But these four elements (physical sensation, behaviour, thoughts and emotions) can interact in different sequences.
Let us take another example:
Jenny plans a picnic and is looking forward to it; then, on the day, it rains. If this event leads her to think “my day is ruined”, then the emotional reaction will be as downcast as the weather, physically she is likely to experience a loss of energetic enthusiasm and her behaviour is likely to become restless and aimless. On the other hand, if the rain leads Jenny to think “ I’ll need a new plan for today”, then any emotional reaction of disappointment will be tempered by thoughts about what else she can do with the day; this will produce a physical response of increased energy for planning and a series of behavioural actions around sorting out an alternative arrangement.
The meaning Jenny attaches to the event (that is, the way she thinks about the rain) determines her emotional, behavioural and physical responses and ultimately, therefore, the outcome for her of this damp day.
When it is a one-off event of only minor consequence, like Jenny’s rainy day, then the effect of the way the event is interpreted is of no particular significance. However, when various events are lumped together in a single category and the same meaning is attached to all of the events in that category, then a pattern is emerging which is of greater influence in the person’s life. It can be very helpful to us at times to have categories to put things into and sets of beliefs or attitudes to which we regularly refer. But sometimes the categories and attitudes can prove problematic.
Once again an example may help illustrate the point:
John thinks he makes a fool of himself whenever he introduces himself to other people. Because of this his behaviour is to hang back and try to avoid having to do it. The emotion that this produces is one of acute anxiety and feelings of awkwardness or even fear. He therefore experiences physical sensations of nervous stomach, heart pounding, sweating and blushing.
To make matters worse these physical sensations make John think that everyone can see he is very anxious and will consider him to be making a fool of himself as he predicted. This makes his emotion of anxiety more intense so that when he does introduce himself his behaviour displays nervousness in his speech, inappropriate or incomplete remarks, a rather unfriendly manner and a very abrupt departure.
By introducing the behaviour of leaving the situation, John’s emotion is one of relief and this makes him think that he really is incapable of dealing with these social situations and should avoid them in future. This point of view is further supported by the physical sensations of exhaustion he feels afterwards which, to him, shows that he’s just not up to doing these things because they take too much out of him.
John has identified a category of events about which he has formed some firm beliefs which pre-determine his responses to future events that he associates with this category. He has acquired a pattern which will cause him problems in the future unless he can recognise it and find ways to change it.
The example of John illustrates the back and forth interplays between the internal elements and also the interaction between the internal world of the person and the external environment around him or her.
In Figure 1.1.1 there is a diagrammatic representation of these interactions. In Cognitive Behaviour Therapy we nickname this commonly used diagram the “Hot Cross Bun” and it was originally devised by Padesky and Mooney (1990). We will refer to it often during this book. It illustrates very clearly that despite its name, cognitive behaviour therapy does not focus on cognitions (or thoughts) and behaviour to the exclusion of feelings. However, for the examples above and in the Hot Cross Bun diagram the word “feelings” has not been used: a distinction is drawn between physical sensations and emotions. In daily life people do not always make these distinctions and will use the word “feelings” to describe both.
Figure 1.1.1 The Hot Cross Bun (adapted from Padesky and Mooney, 1990)
There are times when in cognitive behaviour therapy it is not important to separate the one from the other, but in work with people experiencing symptoms of physical ill health this distinction is often especially relevant; so explaining, understanding and emphasising this distinction can be very important.
Before leaving this introduction to the concepts of CBT, there are two more that cognitive behaviour therapists frequently use. One of these, like the “hot cross bun”, is another image: the “vicious circle” (originally referred to as the “exacerbation cycle” by Beck, 1976). This can be illustrated by returning to John for a moment: he had decided that he could not cope with introducing himself to new people; and this caused him to be anxious; in turn his anxiety caused him to fluff his lines; because he fluffed his lines he believed he was confirmed in his opinion that he could not cope with introducing himself to new people. In this way he completed a “vicious circle” back to his start point.
Self-fulfilling prophesies of this kind are an important feature of what maintains the “distorted thinking and dysfunctional behaviour” referred to by Hawton et al. above. Identifying and breaking these unhelpful circles is an extremely important feature of cognitive behavioural interventions that will be discussed further in this book.
Finally, a quick tour around the cognitive behavioural approach would not be complete without some reference to automatic thoughts. Beck (1976) identified these particular thoughts as an important component in recurrent emotional distress. So what are they?
First, recall the example of the hand near the fire. Once I’ve pulled my hand back from the hot object and decided it is hazardous to me, I do not repeatedly have these thoughts every time I encounter the hot object again. I behave in a way that avoids me hurting myself and I am emotionally wary of being too close to the fire. My reactions seem to be independent of further thinking. Clearly, if I was actually “thoughtless”, I would blunder into it and hurt myself; so I have seen it, recognised it as belonging to a certain category (of hot and harmful objects) and then responded according to that judgement. But this thinking process is very quick and I am hardly aware of doing it. We refer to these thoughts as “automatic”. They are the immediate interpretive and decision-making thoughts that are triggered when certain events occur in our environment. They are so fleeting and we are so little aware of them that we never think them through. This makes them very powerful and influential because we make decisions based on them and yet, because they are hardly noticed and remain unexamined, they are rarely changed by experience or new knowledge.
A realistic reappraisal of the “hot and harmful, therefore stand back” thought about the fire is unlikely to lead to a change in either my perception of the fire or the decision regarding appropriate behaviour. But John, on the other hand, in our last example, experiences recurrent emotional distress because of his automatic thought that he is “incapable of dealing with these social situations and should avoid them in future”. Like the perception of fire, this is also a self-protective strategy that alleviates immediate distress; but it leaves John at a major disadvantage in coping with a category of situations with which he will be faced time after time. Therefore, his episodes of distress will persist until he has had an opportunity to reappraise and change this thought process and the behaviour it directs him towards in favour of a strategy which he finds more effective in both alleviating immediate distress and managing the situations satisfactorily.
“Not coping” may often be considered to be the consequence of reducing emotional discomfort at the expense of satisfactorily dealing with situational demands or responding to demands at a high personal cost to emotional comfort. “Not coping” experiences are enough of a stimulus to begin an application of the cognitive behavioural model including identification of the automatic thoughts that are at work.
In the next chapter we will examine the relevance of this cognitive behavioural approach to people coping with life-changing physical health illnesses and disabilities, including those who expect their lives to be shortened by terminal illness. However, the cognitive behavioural approach is relevant to the experiences of all of us. We all have situations which we perceive as personal triumphs and disasters; we repeatedly fail to cope effectively with some challenges; we take for granted our abilities and skills that others lack. Sometimes people very close to us are puzzled as to why we are so unsure of ourselves in circumstances which they consider to be less difficult, and so confident when we face others they consider more difficult. We surprise ourselves at times by taking a strong dislike to something (or someone) for no logical reason.
Recognising the thinking patterns (cognitions), including the automatic thoughts, which underpin these personal behaviours and emotional reactions, can provide all of us with valuable insights into how we cope day-to-day. If that is good enough for our patients then it should be good enough for us. Learning and understanding the cognitive behavioural approach will be greatly enhanced by applying it to oneself. At the end of every chapter there will be exercises you are asked to complete before moving on through this training workbook. Please stick firmly to that way of working unless you are using this book as part of a training course which is covering the same points in different ways.
Whether you are using this book on a course or training yourself, these first exercises in applying the cognitive behavioural approach to oneself are an important place to start the learning process.
Before you proceed to the next chapter ensure that you take the time to do the exercises included at the end of this chapter. To use this book properly you need to complete all the recommended exercises.
Exercise 1
You may find it easier to fill in some boxes than others. Emotions and physical sensations can be hard to tease apart. Sometimes we do not really notice the thoughts that go with the emotions. The behaviours might be quite small (like a smile or a frown). If you find that one box is still empty, then write in something that is probably the sort of thing that would be the right response. Remember that the responses in the other boxes give you clear clues as to what is likely to be right for this box. For example, if you think “oh dear, what’s wrong?” then the emotion is very likely to be worry or anxiety. If the emotion is annoyance then the thought may be something like “this is an inconvenient time to call” or some similar reason to trigger this emotional response.
Exercise 2
You may find you have quite a complicated set of reactions with more than one thought and emotion. Your behaviours may be a mixture too. In completing the boxes, try to ensure you have identified a specific thought for each emotion and vice versa.
Recommended further reading:
Greenberger D. and Padesky C. A. (1995) Mind Over Mood: A Cognitive Therapy Treatment Manual for Clients, New York: Guilford Press. A popular workbook for self-help from very influential cognitive behaviour therapists.
Padesky, C. A. and Mooney, K .A. (1990) Clinical tip: Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 13–14 also available at www.padesky.com
Sanders, D. and Wills, F. (2005) Cognitive Therapy: An Introduction. London: Sage Publications.
Williams, C. (2003) Overcoming Anxiety: A Five Areas Approach, London: Hodder Headline Group. Along with Overcoming Depression in this same series, this is a British style of CBT selfhelp workbook and is backed up with a self-help website at www.livinglifetothefull.com
Chapter 2
The Relevance of a Cognitive Behavioural Approach for People with a Life-changing Illness
Receiving a diagnosis of multiple sclerosis is not an event that will be received unemotionally by Janet, a 33-year-old happily married mother of two. Her reaction to this news is one of intense distress, as it is to her husband and parents. This is not abnormal; it is not the wrong way to react and there is no reason to suppose that because she reacts in this way that she is doing herself lasting harm. In fact, quite the opposite may be true: that to react quietly and calmly with no show of distress could be storing up an emotional dam-burst for later.
At the point of hearing bad news such as this, it is unlikely that CBT has a useful role to play for most people (whether the patient or a close family member). A cognitive behavioural approach may, however, have an important role in influencing the thoughts and behaviour of those of us who have to break that bad news or provide professional follow-up since our own thoughts of having “failed” or feeling “hopeless about the future” for this patient may affect our communication and the help we offer.
So, the cognitive behavioural approach is relevant to the way in which health care professionals manage their everyday work with people going through the sorts of adverse life experiences that nobody wants and most people dread.
But just because the distress experienced by patients and their families under these circumstances is “normal” and “understandable”, does not mean that there is no place for CBT. People vary greatly in their ability to accept, adapt and cope with the challenges of major health problems, especially life-threatening ones. The methods used in CBT focus on the practical here-and-now experiences in such a way as to be very relevant for those who are struggling to achieve these adjustments.
Early distress may be temporary, but for many people who are faced with life-changing ill health distress will be recurrent: life will become emotionally intense again at every point of change in health status or lifestyle. CBT techniques can be relevant in reducing the emotional intensity of these life events and encouraging a constructive response to new demands. For many people who are challenged in this way and for their families too, elements of CBT may be useful in assisting them to adjust to changed circumstances and also in becoming more resilient to further changes.
So a cognitive behavioural approach can help the health care professional to develop a more constructive attitude and the patient to develop better coping skills. There is, however, a third way in which it can be of relevance and use. The distress experienced by 25–33 per cent of these patients falls within the realms of clinical depression and clinical anxiety. CBT methods have been used to help with these mental health conditions for the past thirty years; they are just as effective when these conditions are reactions to physical health problems. Early use of these methods reduces the risk of a downward spiral into a serious mental health problem requiring specialist mental health expertise.
In examining the relevance of a cognitive behavioural approach to people with life-changing ill health and their families, it is necessary to say something about what it is not. It is not “positive thinking”. It does not involve trying to put a shiny gloss on things; stating positive affirmations in front of the mirror; pretending that things are better than they are; emphasising the good things and ignoring the bad; reassuring oneself that everything will get better; or deluding oneself into believing that this is an opportunity not a threat. These mental tricks may have their place in motivating a sales team, but they usually prove unsustainable in circumstances of intense emotional experiences and they do nothing to equip people for coping well with setbacks.
Returning to our theme of applying CBT to people with life-changing illness, let us look at how we might apply the Hot Cross Bun model to William’s experience of a diagnosis of cancer. Figure 1.2.1 recaps the Hot Cross Bun in a way that will fit our example.
Figure 1.2.1 The cognitive behavioural model
Figure 1.2.2 illustrates a set of responses to this diagnosis of cancer. In this response set, the patient’s thoughts express immediate defeat and self devaluation. Such strongly held beliefs will understandably lead him (we will call him William) to decide on behaviours that are passive and retiring, which (because he is doing nothing) will increase the emotion of hopelessness whilst his loss of drive leaves him with a physical sensation of being very tired all the time. Each of these four elements will feed back into each other and help to maintain or even escalate this depressive response set. We will refer to this as Response Set 1.
Figure 1.2.2 Response Set 1
An alternative response set is illustrated in Figure 1.2.3. This patient (William 2), facing an identical challenge, has a different (but not a “positive”) perspective and the effects are different. The thoughts are acknowledging a difficult future, as in Response Set 1, but this time in a constructive way. These thoughts help him decide on behaviours which are intended to be useful in dealing with his situation. The emotions remain negative in nature but not overwhelming, instead adding some driving force which affects his physical sensations, making him feel energetic (perhaps even restless and tense). The restless energy will probably help him overcome reticence in telling people and getting on with his planning. As the plans develop, so he is able to focus on constructive things that he is doing, which in turn reduces sadness and encourages further helpful ideas.
Figure 1.2.3 Response Set 2
In both these response sets, the interaction between the various elements serves to establish that particular response set. Response Set 1 is neither the right nor the wrong way to respond but, as can be seen in this example, there are consequences that appear to be less pleasant and less helpful than those associated with Response Set 2. As these examples illustrate, once established, the pattern of interaction between the elements and with the external environment maintains this response set through its own feedback loop. A loop can produce benefits (a “virtuous circle”) as in Response Set 2 or disadvantages (a “vicious circle”) as in Response Set 1.
CBT works by capitalising on the interaction between thoughts, emotions, physical sensations and behaviour to encourage a shift from unhelpful responses (such as that in Response Set 1) to others which have the potential for being more useful (such as that in-Response Set 2). By seeking to produce constructive changes in one element, the aim in CBT is to help produce changes in the others and so stop the maintenance of unhelpful response sets.
In breaking into these “vicious circles” and seeking to establish “virtuous” ones, the traditional focus in CBT has been on the thoughts (cognitions) and behaviour because the clinical work has been primarily with people with mental health problems. However, the role of medication in bringing about change in emotions has always been acknowledged and is often an integral part of the cognitive behavioural approach. The use of anti-depressants in particular can be helpful in reducing low moods.
Since his diagnosis with Crohn’s disease, Dave has been feeling very down and fed up, he does not feel like seeing his friends and doing the sorts of things that his girlfriend, Caroline, knows would “bring him out of himself”. Dave feels bad about disappointing Caroline but is sure that nothing is going to lift his mood and that by seeing his friends it would just get worse and bring them down too. He is locked into a vicious circle in which rejecting attempts at change has become part of the problem. Medication can help him change his pervasive emotional state, thus enabling him to think and behave differently. As long as the emotional change brought about by medication is used as an opportunity to bring about changes in thoughts and behaviours then it becomes possible to break the circle. If, on the other hand, the medication is used only to produce respite from the low mood but Dave continues to think and act in the same way as before, then he is very likely to quickly relapse into another low mood once the anti-depressant is withdrawn.
Similarly, it is important not to neglect the significance of the fourth “Hot Cross Bun” element: physical sensations. In addressing the needs of many chronic illness and palliative care patients, this element will be the most pronounced and will be profoundly influencing all the others. Physical sensations may be limiting what can be done, how much pleasure or satisfaction is derived; even how much attention is given to anything other than the physical experiences themselves. Nor do these sensations simply provide information about current bodily state for people with life-changing illness: certain physical sensations for these people may convey expectation about the future and trigger associations with the past: Helen sits by the open window and struggles with her breathing which seems to have become much more laboured since she started watering her pot plants. She suffers from chronic obstructive pulmonary disease (COPD) and does her best to put a brave face on this. However, looking out at her beloved garden and thinking about what she used to be able to do in it, has caused her to become emotionally quite upset and frightened about what the future may have in store. As she became more upset, she experienced changes in physical sensations: her breathing became more rapid and shallow, making her feel dizzy and more frightened. Her behavioural response has been to sit down and to gasp in fresh air. She is convinced that her COPD is getting worse. Anxiety naturally leads to change in the rhythm of breathing; because she suffers from COPD, Helen will be more sensitive to this change than most people. Unfortunately, she erroneously interprets this change as a worsening of her COPD and this, in turn maintains and perhaps heightens the anxiety (and thus the rapid shallow breathing).
It may be that other, non-CBT, interventions will play an important role in breaking into the vicious circles previously mentioned, by making changes in the experience of physical sensations (such as using analgesics for pain relief or oxygen for breathing difficulties). However, if cognitive, behavioural and emotional factors are playing a large part in why these physical sensations are occurring then reliance on physical intervention strategies may lead to inappropriate usage and psychological dependency on these methods of symptomatic relief. At its worst such dependency fuels the problem it is intended to help. For example, if Helen looked to an oxygen cylinder for help rather than an open window, then she could become anxious with breathing difficulties simply because her cylinder was running low or at the other end of the house.
It may be that the physical sensations are not amenable to very much change, in which case reducing their influence on thoughts, behaviour and emotion becomes the CBT challenge. Patricia’s multiple sclerosis is quite severe and physical experiences include a host of unpleasant sensory disturbances as well as pain, fatigue and muscle control difficulties. Understandably, she has found coping with the relapsing-remitting nature of her disease extremely difficult. Emotionally, she goes to bed each night afraid to go to sleep because of thoughts that she might wake up with more problems the next day. She complains of feeling useless, of being left on the side-lines and of being cheated of the ability to enjoy family life. In terms of her behaviour, preoccupation with disease progression and her poor sleep pattern make it hard for Patricia to play any significant role in daily life with her family. If she is to achieve her ambition of becoming more useful and involved, she will need to be less influenced by symptoms and what the future might bring and more by how she can make a worthwhile contribution despite the current limitations of her physical condition. This will be a very difficult shift in focus of attention for Patricia to make and she will also need to re-evaluate her priorities in her roles within the family. In order to do this she will need to look at these roles from the perspective of the other family members as well as re-examining her own beliefs about what is important or not. A cognitive behavioural approach will enable her to do this effectively but, as well as her own motivation to achieve this goal, she will probably need the help of someone skilled in a cognitive behavioural approach.
Before looking at the various strategies that one might employ in helping Patricia to make these changes, it will be important to establish that this truly is a goal that she is motivated to achieve and that the problems that are stopping her from achieving it at the moment are fully understood. A truly cognitive behavioural approach requires that there is a careful assessment of the interplay between environment, thoughts, behaviour, emotions and physical sensations, so that a formulation can be developed that attempts to explain what causes and maintains the problems. Once this has been done, goal setting needs equally careful attention to ensure that goals address the identified needs and are shared and understood by the patient and the cognitive behavioural practitioner.
Each of these stages of the cognitive behavioural approach will be examined in closer detail in later chapters after having first reviewed the evidence base for using this approach and then considered the communication skills necessary to fulfil these stages.
Before you proceed to the next chapter ensure that you take the time to do the exercises included at the end of this chapter. To use this book properly you need to complete all the recommended exercises.
Exercise 1
Think about what it would be like to be this man:
Geoffrey is a 45-year-old married man with two sons aged 12 and 8. He works as a health service physiotherapist.
A former rugby player and rower, he is now involved with youth teams in both sports. Recently he has been developing a keen interest in competitive sailing. He also enjoys hill-walking and some rock climbing.
His wife is a nurse and shares his enthusiasm for sports and outdoor recreational activities. However, the marriage has been under some strain in the past two years since he had a brief affair with another woman.
Both boys hero-worship their father and take a keen interest in sports to impress him.
His elderly parents who live five miles away are in poor health and depend on him and his wife for shopping and running around. They too rather hero-worship their son.
He was diagnosed with motor neurone disease two months ago following concerns about strange difficulties with speech and odd throat sensations. With each of the next series of exercises we can only know the answers by carefully exploring the experiences with Geoffrey himself. Each person makes individual interpretations of events, draws conclusions relevant to their own perception of themselves and the world and reacts in a way that is only fully understandable in that context. So, whilst we may have some fairly shrewd ideas about how this man might be responding, in therapy we cannot afford the luxury of making these assumptions. However, we can, for the purposes of these exercises, have a go at being in Geoffrey’s shoes for a few minutes and guess at how we might respond if we were him.
Exercise 2
In his quiet moments what do you think are likely to be Geoffrey’s most persistent recurrent thoughts?
Exercise 3
What thoughts will probably accompany each of these emotions?
Emotion
Thought
Guilt
Frustration
Despair
Worthlessness
Panic
Exercise 4
Which emotions will probably accompany these physical sensations?
Physical Sensation
Emotion
Restlessness
Breathlessness
Exhaustion
Cold sweat
Tearfulness
Exercise 5
What thoughts and emotions might account for these behaviours?
Behaviour
Emotion
Thought
Shouting at his sons
Vigorous exercising
Avoiding his parents
Refusing to see friends
Showing no affection to his wife
In each of these exercises, it should have been possible to identify a thought or emotion that is natural companion to the other responses described. The thought should to some extent “explain” the emotion, and the emotion “explain” the behaviour. If your comments do not quite fit together in this way, look again to see if you can find a closer match. It is perhaps worth remembering whilst trying to find a suitable match that even at our most emotional and seemingly irrational, we are surprisingly logical (albeit that sometimes the logic is faulty).
Recommended further reading:
David, L. (2006) Using CBT in General Practice: The 10 Minute Consultation, Bloxham: Scion Publishing.
Moorey, S. (1996) When bad things happen to rational people: cognitive therapy in adverse life circumstances. Pages 450-469 in Salkovskis, P. M. (ed.) Frontiers of Cognitive Therapy, New York: Guilford Press.
Moorey, S. and Greer, S. (2002) Cognitive Behaviour Therapy for People with Cancer, New York: Oxford University Press.
White, C. (2001) Cognitive Behaviour Therapy for Chronic Medical Problems. A Guide to Assessment and Treatment in Practice. John Wiley & Sons, Ltd.
Williams, J. M. G. and Moorey (1989) The wider application of cognitive therapy: the end of the beginning. Pages 227–250 in Scott J., Williams J. M. G. and Beck A. T. (eds.) Cognitive Therapy in Clinical Practice, London: Routledge.
Chapter 3
Does Cognitive Behaviour Therapy Work? The Evidence Base
Introduction
The aim of this chapter is to provide an overview of the literature exploring the efficacy of cognitive behavioural approaches with life-changing illness. We shall see that the evidence base for CBT with a range of psychological difficulties in a mental health context is both substantial and impressive. We will then turn to the research within the specialist field and see that, rather encouragingly, whilst the evidence for applying cognitive behavioural approaches more specifically to life-changing illness is currently less substantial, it is still very promising.
Overall, there are studies that suggest that CBT can in some cases help people facing difficult and challenging illnesses to achieve a better quality of life and even increase their duration of survival. There is also evidence that CBT is cost effective, can reduce wastage of resources and, as in the case of pain, can play an important role in preventing patients from developing chronic and disabling conditions. The evidence base also suggests that CBT can be delivered successfully by therapists from different backgrounds.
As a note of caution, however, as with many areas of research, the literature exploring the efficacy of CBT with life-changing illness is fraught with methodological shortcomings and it is important that results are interpreted in this context. Additionally, where there is evidence in favour of a particular approach, there are often studies that contradict these findings so that studies often produce mixed results overall. Reviewers rightly critique studies rigorously, so that an accurate picture can emerge. For example, a common criticism of research is that where studies lack a comparison group it is not possible to attribute any changes observed to the CBT approach under investigation. It is equally possible that non specific therapeutic factors were the active ingredient in the process of change. However, whilst methodological shortcomings can lead to findings being overstated, the converse is also true. There are many ways in which study design can lead to the effectiveness of an intervention being underestimated.
Whilst reviewers tend to focus heavily on ways in which studies may have overestimated the effects of an intervention, it is important to balance this by considering ways in which in clinical practice an intervention may fare better. Ultimately our aim is to decipher what the evidence points to in the way of current best practice. It is therefore important to review the literature from this pragmatic standpoint. Where there are strong theoretical grounds underpinning the application of CBT to life-changing illness, a lack of positive findings may be due to the way in which the research has been conducted. Before reading the evidence base it is therefore helpful to be aware of some of the ways in which research may mask the effectiveness of an intervention.
When evaluating research, then, whilst it is important to be aware of ways in which research design could overestimate the effectiveness of an intervention, it is also important to consider whether there are grounds to suspect that in clinical practice a better outcome might be realised. This does not mean we should ignore the evidence base, but rather appreciate that it is only as good as the quality of the research being reviewed. When applying findings to practice there may be grounds for suspecting an intervention will be fruitful that has as yet little or no good evidence in its favour. At this juncture, your attention is drawn to the section on applying research findings to clinical practice, found towards the end of the chapter. This section expands on some of the points made above and discusses practical issues that arise in relation to applying the evidence base to clinical practice.
Students should persevere in reading this chapter thoroughly and carefully, even though it may be heavy going at times. A solid grounding in the evidence base is an essential component of applying a cognitive behavioural approach: good practice requires that interventions offered to the patient have proven efficacy and, quite rightly, an increasing number of patients want to know what evidence there is in favour of the different options presented to them.
A further reason for being familiar with the evidence base is that in financially limited health care systems, managers increasingly require proposals for new service developments, such as introducing cognitive behavioural approaches, to include data that backs up the assertions of the likely benefits of these developments. The material contained in this chapter may be helpful in negotiating the necessary resources to practice cognitive behavioural approaches, including protected time for supervision. It is also to be hoped that by reading through the evidence in support of CBT and its application to life-changing illness you may further increase your motivation to apply cognitive behavioural approaches to your own practice, perhaps even add to the evidence base.
In preparing the material for this chapter, the authors have drawn heavily on review articles that have explored the literature in detail. The key findings have been presented in summary format as a quick guide and reference for the interested practitioner seeking to apply evidence-based practice to their work. The chapter covers the areas of cancer and palliative care, cardiac problems, chronic pain, multiple sclerosis, diabetes, chronic obstructive pulmonary disease and Parkinson’s disease. However, even if you practice in an area not covered by this chapter, there is much here that will be relevant. Reading the summaries will provide a flavour of what can be achieved with CBT, alert you to issues that are likely to arise with any life-changing illness and give you a feel for how to critique studies evaluating the effectiveness of CBT within your area of expertise.
Additionally, you are strongly encouraged to supplement the contents of this chapter with literature searches of your own to explore areas of interest in more detail, and ensure you remain informed of up-to-date work in the field. The limitations in research design listed above suggest that the effectiveness of CBT may have been underestimated in a number of studies. There is good reason to suppose, therefore, that in time, larger scale, better designed studies, will produce a more substantial evidence base that will further elucidate the effectiveness of applying CBT to life-changing illness. The exercise at the end of the chapter will help you to get started with making your own literature searches in this field.
The evidence base for CBT
Overall, as we shall see, there is an impressive evidence base for the effectiveness of CBT in a mental health context, strong theoretical grounds for applying CBT to address psychological issues associated with life-changing illness and a growing evidence base within the specialist field.
In 2001, the Department of Health (DoH) and the National Institute for Clinical Excellence (NICE) commissioned an extensive review of the literature so that “Treatment Choice in Psychological Therapies and Counselling” could be identified. A meta-review (a review of a collection of reviews) of the best available evidence was conducted and it was concluded that there is good evidence that CBT is effective with depression, panic disorder, social phobia, obsessive compulsive disorder, bulimia and generalised anxiety disorder.
This review found an impressive evidence base for the efficacy of CBT with a range of psychological difficulties in a mental health context. This is very relevant to our exploration of the evidence base for life-changing illness. There is a significant overlap between the issues that arise in a mental health context and those that arise in relation to ill health. For instance, life-changing illness may lead to difficulties in adjusting to losses and changes that result in clinical depression; and disfigurement caused by physical illness or its treatment may lead to body image issues that trigger social phobia. Providing care is taken to adapt interventions to take account of the effects of illness-related factors such as pain, fatigue or the side effects of medication, there is no reason to assume that the evidence base generated by work in a mental health context is not applicable to patients whose primary diagnosis is a physical health disorder. Consistent with this view, the meta-review also found good evidence for the efficacy of CBT with chronic pain and more limited but growing evidence for other somatic complaints including chronic fatigue, pelvic pain and pre menstrual syndrome. That is not to say the review would not have found evidence in favour of CBT for other physical health problems, however, the authors restricted the scope of their review to a small number of somatic complaints regarded as highly relevant to patients presenting in GP surgeries.
Bearing in mind that our patients with life-changing illnesses experience the same sources of psychological distress as the rest of the population, there is very good evidence here in favour of CBT for a range of psychological disorders relevant to working with people with life-changing illness.
In the following sections, the evidence bases for a range of life-changing illnesses are presented. Each section provides a brief introduction, highlights common psychological issues that arise in relation to that illness and provides a summary of some of the findings of evaluation studies in the area.
Cancer and palliative care
There are many different types and causes of cancer and it is beyond the scope of this chapter to go into details. Suffice it to say, however, that receiving a diagnosis of cancer is potentially a highly distressing experience. Cancer brings with it significant psychological challenges such as coping with uncertainty about the future and loss of control over one’s health. It is not so much what the diagnosis actually means but what the individual perceives it to mean that will determine the level of distress experienced. In addition, medical and surgical treatment of cancer can be very demanding and present the patient with both temporary and permanent losses and changes. For instance, loss of energy and sense of wellbeing are common problems associated with chemotherapy and surgery may change the body and alter body image, as with mastectomy.
Given the likely losses and changes associated with having cancer, a period of psychological adjustment would be expected as the patient grapples to make sense of their experience. Perhaps not surprisingly, a significant number of individuals (studies suggest up to 20 per cent) will struggle to make this adjustment. They will present with clinically significant levels of anxiety and depression, body image issues and even symptoms of psychological trauma.
