WORKSHOPS - 'Extending the application of CBT'

THURSDAY 6th APRIL

Worried Sick? Extending the application of the CBT from health anxiety to Medically Unexplained Symptoms (MUS) and Long Term Medical Conditions (LTC)

Paul Salkovskis, University of Bath

Workshop 1 - More information...

Cognitive behavioural approaches to health anxiety have been shown to be effective in RCTs in people where the main presenting problem is anxiety focussed on health, and in those seeking medical help in hospital found to have high levels of health anxiety. There are also indications that CBT could be effective in Medically Unexplained Symptoms (MUS) and in Long Term Physical Health problems (LTC) associated with relatively severe psychological distress.

In this workshop, Paul will describe the cognitive behavioural theory of health anxiety and how that has been applied to the development and validation of a treatment which evidence suggests is both effective and cost effective, and which can be relatively easily learned by health professionals. The main components of this treatment will be described and illustrated, with the emphasis on the clinical “how to”.

The complex link between health anxiety and problems in general medical settings (both primary and secondary care) will be discussed, and evidence for generalisation to both MUS and LTC evaluated. The adaptations required for the application of the health anxiety treatment in this context will then be outlined, particularly focusing on the fact that anxiety and perception of threat alone will not always account for the maintenance of psychological distress in such problems. A trans-diagnostic model will be detailed which allows the application of a transdiagnsotic CBT approach to therapy. However, it is emphasized that attention to specific issues is also required, so the treatment is in fact a hybrid of transdiagnostic and specific elements. The way such treatment should be conducted, from screening, assessment and formulation and engagement through to more active treatment, behavioural experiments and generalization strategies will be outlined in the context of MUS such as IBS, chronic pain, CFS and so on.

The importance of using an empirically and theoretically grounded transdiagnostic approach as a way of ensuring high quality therapy is thus considered in the context of the need to address the specific issues in symptomatically diverse problems such as chronic pain, Irritable bowel, chronic fatigue and so on. Core elements of treatment include engagement and developing a shared understanding supplemented by “modules” addressing specific aspects of MUS in the later stages of treatment, with behavioural experiments cutting across both aspects of the treatment. Treatment fundamentals and details will be discussed and, where possible, demonstrated.

This workshop provides the foundation for CBT for health anxiety and its application to a range of presentations including MUS and LTC in addition to where health anxiety is the primary problem.

Key learning objectives:
1. To understand better the interplay between health concerns and physical symptoms with and without medical explanations
2. To develop engagement skills with patients where physical health issues are prominent
3.  To develop skills in assessment as the foundation for formulation and shared understanding
4. To apply formulation based CBT to such cases

References
Salkovskis, P. M., Warwick, H., & Deale, A. C. (2003). Cognitive-behavioral treatment for severe and persistent health anxiety (hypochondriasis). Brief Treatment and Crisis Intervention, 3(3), 353.

Salkovskis, P. M., Gregory, J. D., Sedgwick-Taylor, A., White, J., Opher, S., & Ólafsdóttir, S. (2016). Extending Cognitive-Behavioural Theory and Therapy to Medically Unexplained Symptoms and Long-Term Physical Conditions: A Hybrid Transdiagnostic/Problem Specific Approach. Behaviour Change, 1-21.

Wattar, U., Sorensen, P., Buemann, I., Birket-Smith, M., Salkovskis, P. M., Albertsen, M., & Strange, S. (2005). Outcome of cognitive-behavioural treatment for health anxiety (hypochondriasis) in a routine clinical setting. Behavioural and Cognitive Psychotherapy, 33(02), 165-175.

Professor Paul Salkovskis is Professor of Clinical Psychology and Applied Science at the University of Bath where he is director of a joint University/NHS national specialist anxiety disorder clinic and Programme Director for the Clinical Psychology Doctorate Programme at Bath. He is also currently Editor of Behavioural and Cognitive Psychotherapy, and on the editorial board of many international journals. He is Patron of several OCD and anxiety disorder charities. He has published over 300 articles and chapters on the understanding and treatment of psychological problems and anxiety disorders. He’s been round the block a few times, and is noted for his reticence in terms of expressing his view.


Persistent physical symptoms: something old, new, borrowed and blue

Trudie Chalder, King’s College London

Workshop 2 - More information...

Medically Unexplained Symptoms (MUS) are defined as persistent bodily symptoms with functional disability but no explanatory pathology.  Other terms include Somatic Symptom Disorder (SDD) which is used in the Diagnostic Statistics Manual (DSM-5). This refers to persistent (6 months or more) and clinically significant somatic complaints accompanied by excessive and disproportionate health-related thoughts, feelings and behaviours regarding the symptoms (American Psychiatric Association, 2013).

There are several advantages of the new term.  Firstly, it does not include the word ‘unexplained’ and describes a positive conceptualisation of symptoms based on presence rather than absence.  Secondly, it helps to move beyond mind/body dualism such that inexplicability does not equal psychiatric disorder.  Thirdly, it encourages a positive therapeutic alliance such that patients are less likely to perceive stigma from others related to symptoms being ‘all in their mind’ (Dimsdale et al., 2013). 

Following this move towards a less dualistic description of somatic symptoms, a healthy population (Marks & Hunter 2014) and patients with CFS (Picariello et al., 2015) stated that they preferred the term ‘Persistent Physical Symptoms’ (PPS).  The advantage of the term PPS is that it includes symptoms associated with medically diagnosed long term conditions such as diabetes, rheumatoid arthritis and multiple sclerosis which may present co-morbidly with MUS. More specific labels such as chronic fatigue syndrome (CFS), irritable bowel syndrome (IBS), fibromyalgia (FM), non cardiac chest pain (NCCP) and chronic pain are used in clinical practice. 

The management of these patients is a significant challenge to the NHS with healthcare utilisation costing almost twice as much as other patients. Epidemiological studies show that approximately 50% of patients in different specialty hospital clinics present with MUS.  Psychiatric co-morbidity rates of 50% are observed and are higher than those found in healthy control subjects or patients with similar organic diseases.  Research suggests that both cognitive and behavioural responses perpetuate symptoms and disability. A transdiagnostic but formulation based treatment approach based on cognitive behavioural models that integrate evidence of predisposing, precipitating and perpetuating factors is suggested. Interventions which follow the formulation will be discussed.

Key learning objectives:
1.To broadly gain an understanding of the impact of persistent physical symptoms (PPS)
2. To gain an understanding of the specific cognitive, behavioural responses that may be perpetuating the symptoms and disability
3. To gain an understanding of the most effective interventions for a range of PPS

References
Deary, V., Chalder, T., Sharpe, M. (2007).  The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review.  Clinical Psychology Review 27, 781–797.

Dimsdale, J., Creed, F., Escobar, J. et al. (2013).  Somatic Symptom Disorder:  An important change in DSM.  Journal of Psychosomatic Research, 75, 3, 223-228.

Trudie Chalder is Professor of Cognitive Behavioural Psychotherapy at King’s College London. She has worked as a clinician and a researcher in the area of long term conditions and medically unexplained symptoms for over 25 years. She develops specific cognitive behavioural models for understanding and treating these conditions and evaluates the approaches within the context of randomised controlled trials in primary and secondary care. Her research involves investigating not only whether treatment works in the context of gold standard randomised controlled trials but how and for whom it works. Her work spans adolescents and adults.

Trudie has published approximately 200 articles. She was the President of the British Association of Behavioural and Cognitive Psychotherapy and is an Editor of the Journal of Mental Health.


The Eyes, Ears, and Heart of ACT: Truly FUNCTIONAL CONTEXTUAL Applications of Psychological Flexibility for Chronic Pain and Related Conditions

Lance  McCracken, King’s College London

Workshop 3 - More information...

ACT has been developing in clinical practice for chronic pain in the UK for at least 17 years. There are now more than eleven randomized controlled trials of Acceptance and Commitment Therapy (ACT) for chronic pain and 18 in other chronic conditions. There are also several up to date systematic reviews showing that ACT is at least promising for many conditions and effective in others, and most likely equal to current, best, evidence-based treatments.  ACT appears cost effective for chronic pain in a most recent review.  ACT is not clearly superior to conventional CBT based on current evidence.  As ever more high quality studies are needed to fuel further development including in particular moderator and mediator analyses and studies of how to improve competency and fidelity.  In the meantime, there is certainly enough evidence to support the application of ACT and the psychological flexibility (PF) model in clinical practice.  There are also accumulating data on some of the secondary advantages of ACT: patients may prefer it, treatment providers may find it relevant to their own lives, and it may promote effectiveness and wellbeing at work, particularly if it is applied as it is meant to be, to the treatment provider as well as the treatment recipient.

Training and applications of ACT and PF appear to move through stages: (a) hybrid delivery of “ACT+CBT,” (b) linear limited delivery of familiar methods, (c) linear delivery of both familiar and unfamiliar methods, and finally, at some point, (d) fluid dynamic delivery guided by processes and principles. This workshop will take a smaller number of key concepts and principles and show how they can guide a more fluid and dynamic version of ACT.  These concepts include the following: contextual sensitivity, sense-making, perspective-taking, and the pursuit of meaning. We will also practice applying the simple set of process terms: “open, aware, and engaged.” This workshop may be interesting to anyone wanting to learn more about ACT and will be most useful for people who already have at least and introductory knowledge and want to explore ways to enhance their practice.

This workshop will provide participants with guides and methods that can be immediately used in clinical practice.  It will provide an introduction to ACT for those with limited familiarity and improved the insights and those who already have developed an introductory level.

Key learning objectives:
1. To gain familiarity for the evidence for ACT and PF in chronic pain and other chronic conditions.
2. To understand some of the key principles underlying the psychological flexibility model and how to apply them.
3. To apply processes of “open, aware, and engaged” in practice.

References
Graham, C. D., Gouick, J., Krahé, C., & Gillanders, D. (2016). A systematic review of the use of Acceptance and Commitment Therapy (ACT). In chronic disease and long-term conditions. Clinical Psychology Review, 46, 46-58.

Hughes, L. S., Clark, J., Colclough, J. A., Dale, E., & McMillian, D. (2017). Acceptance and Commitment Therapy (ACT) for chronic pain; A systematic review and meta-analysis. The Clinical Journal of Pain, doi: 10.1097/AJP.0000000000000425.

McCracken, L. M., & Vowles, K. E. (2014). Acceptance and Commitment Therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69, 178-187.

Lance McCracken is Professor of Behavioural Medicine at King’s College London.  He has held his post in the Health Psychology Section of the Psychology Department in the Institute of Psychiatry, Psychology, and Neuroscience (IoPPN) since 2011. He is also a Consultant Clinical Psychologist and the Psychology Lead at the INPUT pain management centre at St Thomas’ Hospital in London. He is on the editorial boards for numerous journals in the fields of pain, health psychology, and cognitive behaviour therapy. He is a clinical researcher and has over 220 published scientific articles and chapters and two books, most of these on treatment development for chronic pain, dating back more than 20 years.


What to do when the manual runs out? Using CBT when working long-term or with complexity with people with eating disorders.

Vicki Mountford, King’s College London

Workshop 4 - More information...

Evidence-based CBT treatments and NICE guidelines often recommend standard lengths of treatment for patients with eating disorders – typically up to 40 sessions for an individual with anorexia nervosa and 20 sessions for an individual with bulimia nervosa. There are sound clinical rationales for such limits and it is important that a course of CBT does not become indefinitely open-ended with a loss of clear goals and therapist and client expectations. However, there are circumstances where such standards may not be applicable or useful, for example, individuals who move across services or have multiple admissions, those who have a severe and lengthy illness or where there is additional complexity, for example, physical or mental comorbidity.

This workshop aims to support attendees in developing and delivering coherent and principle-driven CBT in the care of individuals with long-standing or complex needs. Attendees will feel more confident and empowered to work with this challenging client group, whilst remaining aware of the dilemmas and demands associated with this work.

Key learning objectives:
1.   To discuss issues regarding clinical decision making and treatment planning in relation to complex or long-standing cases.
2. Aware of adaptations to treatment when working with complexity or longevity.
3. Awareness of managing such work and therapist wellbeing within the system.

This interactive workshop will emphasise real-life clinical practice, exploring the difficulties, dilemmas and rewards of such work. In particular we will explore the impact of long-term comorbid physical health conditions upon CBT, how to develop formulations, difficulties with ending and holding the patient and system in mind. We will consider when we may need to ‘do something different’, especially for those individuals caught in the trap of multiple admissions. We will also explore how to manage the risk of therapist burnout. Clinical vignettes, including formulations and treatment plans will illustrate the points discussed. Small group work and discussion will explore participants own experiences of working in this way.

References
Bamford, B. & Mountford, V.A. (2012). Cognitive behavioural therapy for individuals with longstanding anorexia nervosa: adaptations, clinician survival and system issues. European Eating Disorders Review, 20, 49-59.

Mountford, V.A., Tatham, M., Turner, H. & Waller G. (in press). Working with complexity in the Eating Disorders. The Cognitive Behaviour Therapist.

Startup, H., Mountford, V.A., Lavender, A. & Schmidt, U. (2015). Cognitive Behavioural Case Formulation in Complex Eating Disorders. In Eds. N. Tarrier & J. Johnson. Case Formulation in Cognitive Behaviour Therapy: The Treatment of Challenging and Complex Cases. Routledge.

Dr Vicki Mountford has specialised in the field of eating disorders for over 15 years. She currently works at the Eating Disorder Service at South London and Maudsley NHS Trust, covering inpatient, outpatient and daycare services. She is a BABCP accredited practitioner, supervisor and trainer. She has lectured and published widely in the area of eating disorders and CBT. Her current research interests include early intervention and CBT in the eating disorders.