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What is Deinstitutionalisation?

Published on by Andrew Marshall16 Comments

Introduction

Deinstitutionalisation is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability. In the late 20th century, it led to the closure of many psychiatric hospitals, as patients were increasingly cared for at home, in halfway houses and clinics, in regular hospitals, or not at all.

Deinstitutionalisation works in two ways:

  • The first focuses on reducing the population size of mental institutions by releasing patients, shortening stays, and reducing both admissions and readmission rates.
  • The second focuses on reforming psychiatric care to reduce (or avoid encouraging) feelings of dependency, hopelessness and other behaviours that make it hard for patients to adjust to a life outside of care.

The modern deinstitutionalisation movement was made possible by the discovery of psychiatric drugs in the mid-20th century, which could manage psychotic episodes and reduced the need for patients to be confined and restrained. Another major impetus was a series of socio-political movements that campaigned for patient freedom. Lastly, there were financial imperatives, with many governments also viewing it as a way to save costs.

The movement to reduce institutionalisation was met with wide acceptance in Western countries, though its effects have been the subject of many debates. Critics of the policy include defenders of the previous policies as well as those who believe the reforms did not go far enough to provide freedom to patients.

Brief History

19th Century

The 19th century saw a large expansion in the number and size of asylums in Western industrialised countries. In contrast to the prison-like asylums of old, these were designed to be comfortable places where patients could live and be treated, in keeping with the movement towards “moral treatment”. In spite of these ideals, they became overstretched, non-therapeutic, isolated in location, and neglectful of patients.

20th Century

By the beginning of the 20th century, increasing admissions had resulted in serious overcrowding, causing many problems for psychiatric institutions. Funding was often cut, especially during periods of economic decline and wartime. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, ill-treatment, and abuse of patients; many patients starved to death. The first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s.

Origins of the Modern Movement

The advent of chlorpromazine and other antipsychotic drugs in the 1950s and 1960s played an important role in permitting deinstitutionalisation, but it was not until social movements campaigned for reform in the 1960s that the movement gained momentum.

A key text in the development of deinstitutionalisation was Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, a 1961 book by sociologist Erving Goffman. The book is one of the first sociological examinations of the social situation of mental patients, the hospital. Based on his participant observation field work, the book details Goffman’s theory of the “total institution” (principally in the example he gives, as the title of the book indicates, mental institutions) and the process by which it takes efforts to maintain predictable and regular behaviour on the part of both “guard” and “captor,” suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of “institutionalising” them.

Franco Basaglia, a leading Italian psychiatrist who inspired and was the architect of the psychiatric reform in Italy, also defined mental hospital as an oppressive, locked and total institution in which prison-like, punitive rules are applied, in order to gradually eliminate its own contents, and patients, doctors and nurses are all subjected (at different levels) to the same process of institutionalism. Other critics went further and campaigned against all involuntary psychiatric treatment. In 1970, Goffman worked with Thomas Szasz and George Alexander to found the American Association for the Abolition of Involuntary Mental Hospitalisation (AAAIMH), who proposed abolishing all involuntary psychiatric intervention, particularly involuntary commitment, against individuals. The association provided legal help to psychiatric patients and published a journal, The Abolitionist, until it was dissolved in 1980.

Reform

The prevailing public arguments, time of onset, and pace of reforms varied by country. Leon Eisenberg lists three key factors that led to deinstitutionalisation gaining support. The first factor was a series of socio-political campaigns for the better treatment of patients. Some of these were spurred on by institutional abuse scandals in the 1960s and 1970s, such as Willowbrook State School in the United States and Ely Hospital in the United Kingdom. The second factor was new psychiatric medications made it more feasible to release people into the community and the third factor was financial imperatives. There was an argument that community services would be cheaper. Mental health professionals, public officials, families, advocacy groups, public citizens, and unions held differing views on deinstitutionalisation.

However, the 20th Century marked the development of the first community services designed specifically to divert deinstitutionalisation and to develop the first conversions from institutional, governmental systems to community majority systems (governmental-NGO-For Profit). These services are so common throughout the world (e.g. individual and family support services, groups homes, community and supportive living, foster care and personal care homes, community residences, community mental health offices, supported housing) that they are often “delinked” from the term deinstitutionalization. Common historical figures in deinstitutionalisation in the US include Geraldo Rivera, Robert Williams, Burton Blatt, Gunnar Dybwad, Michael Kennedy, Frank Laski, Steven J. Taylor, Douglas P. Biklen, David Braddock, Robert Bogdan and K.C. Lakin. in the fields of “intellectual disabilities” (e.g. amicus curae, Arc-US to the US Supreme Court; US state consent decrees).

Community organizing and development regarding the fields of mental health, traumatic brain injury, aging (nursing facilities) and children’s institutions/private residential schools represent other forms of diversion and “community re-entry”. Paul Carling’s book, Return to the Community: Building Support Systems for People with Psychiatric Disabilities describes mental health planning and services in that regard, including for addressing the health and personal effects of “long term institutionalisation”. and the psychiatric field continued to research whether “hospitals” (e.g. forced involuntary care in a state institution; voluntary, private admissions) or community living was better. US states have made substantial investments in the community, and similar to Canada, shifted some but not all institutional funds to the community sectors as deinstitutionalisation. For example, NYS Education, Health and Social Services Laws identify mental health personnel in the state of New York, and the two term Obama Presidency in the US created a high-level Office of Social and Behavioural Services.

The 20th Century marked the growth in a class of deinstitutionalisation and community researchers in the US and world, including a class of university women. These women follow university education on social control and the myths of deinstitutionalization, including common forms of transinstitutionalisation such as transfers to prison systems in the 21st Century, “budget realignments”, and the new subterfuge of community data reporting.

Consequences

Community services that developed include supportive housing with full or partial supervision and specialised teams (such as assertive community treatment and early intervention teams). Costs have been reported as generally equivalent to inpatient hospitalisation, even lower in some cases (depending on how well or poorly funded the community alternatives are). Although deinstitutionalisation has been positive for the majority of patients, it also has shortcomings.

Criticism of deinstitutionalisation takes two forms. Some, like E. Fuller Torrey, defend the use of psychiatric institutions and conclude that deinstitutionalisation was a move in the wrong direction. Others, such as Walid Fakhoury and Stefan Priebe, argue that it was an unsuccessful move in the right direction, suggesting that modern day society faces the problem of “reinstitutionalisation”. While coming from opposite viewpoints, both sets of critics argue that the policy left many patients homeless or in prison. Leon Eisenberg has argued that deinstitutionalisation was generally positive for patients, while noting that some were left homeless or without care.

Misconceptions

There is a common perception by the public and media that people with mental disorders are more likely to be dangerous and violent if released into the community. However, a large 1998 study in Archives of General Psychiatry suggested that discharged psychiatric patients without substance abuse symptoms are no more likely to commit violence than others without substance abuse symptoms in their neighbourhoods, which were usually economically deprived and high in substance abuse and crime. The study also reported that a higher proportion of the patients than of the others in the neighbourhoods reported symptoms of substance abuse.

Findings on violence committed by those with mental disorders in the community have been inconsistent and related to numerous factors; a higher rate of more serious offences such as homicide have sometimes been found but, despite high-profile homicide cases, the evidence suggests this has not been increased by deinstitutionalisation. The aggression and violence that does occur, in either direction, is usually within family settings rather than between strangers.

Adequacy of Treatment and Support

Common criticisms of the new community services are that they have been uncoordinated, underfunded and unable to meet complex needs. Problems with coordination arose because care was being provided by multiple for-profit businesses, non-profit organisations and multiple levels of government.

Torrey has opposed deinstitutionalisation in principle, arguing that people with mental illness will be resistant to medical help due to the nature of their conditions. These views have made him a controversial figure in psychiatry. He believes that reducing psychiatrists’ powers to use involuntary commitment led to many patients losing out on treatment, and that many who would have previously lived in institutions are now homeless or in prison.

Other critics argue that deinstitutionalisation had laudable goals, but some patients lost out on care due to problems in the execution stage. In a 1998 study of the effects of deinstitutionalisation in the United Kingdom, Means and Smith argue that the program had some successes, such as increasing the participation of volunteers in mental healthcare, but that it was underfunded and let down by a lack of coordination between the health service and social services.

Reinstitutionalisation

Some mental health academics and campaigners have argued that deinstitutionalisation was well-intentioned for trying to make patients less dependent on psychiatric care, but in practice patients were still left being dependent on the support of a mental healthcare system, a phenomenon known as “reinstitutionalisation” or “transinstitutionalisation”.

The argument is that community services can leave the mentally ill in a state of social isolation (even if it is not physical isolation), frequently meeting other service users but having little contact with the rest of the public community. Fakhoury and Priebe said that instead of “community psychiatry”, reforms established a “psychiatric community”. Julie Racino argues that having a closed social circle like this can limit opportunities for mentally ill people to integrate with the wider society, such as personal assistance services.

Thomas Szasz, a longtime opponent of involuntary psychiatric treatment, argued that the reforms never addressed the aspects of psychiatry that he objected to, particularly his belief that mental illnesses are not true illnesses but medicalised social and personal problems.

Medication

There was an increase in prescriptions of psychiatric medication in the years following deinstitutionalisation. Although most of these drugs had been discovered in the years before, deinstitutionalisation made it far cheaper to care for a mental health patient and increased the profitability of the drugs. Some researchers argue that this created economic incentives to increase the frequency of psychiatric diagnosis (and related diagnoses, such as ADHD in children) that did not happen in the era of costly hospitalised psychiatry.

In most countries (except some countries that are either in extreme poverty or are hindered from importing psychiatric drugs by their customs regulations), more than 10% of the population are now on some form of psychiatric medicine. This increases to more than 15% in some countries such as the United Kingdom. A 2012 study by Kales, Pierce and Greenblatt argued that these medicines were being overprescribed.

Victimisation

Moves to community living and services have led to various concerns and fears, from both the individuals themselves and other members of the community. Over a quarter of individuals accessing community mental health services in a US inner-city area are victims of at least one violent crime per year, a proportion eleven times higher than the inner-city average. The elevated victim rate holds for every category of crime, including rape/sexual assault, other violent assaults, and personal and property theft. Victimisation rates are similar to those with developmental disabilities.

Worldwide

Hong Kong

In Hong Kong, a number of residential care services such as halfway houses, long-stay care homes, supported hostels are provided for the discharged patients. In addition, community support services such as rehabilitation day services and mental health care have been launched to facilitate the patients’ re-integration into the community.

Japan

Unlike most developed countries, Japan has not followed a program of deinstitutionalisation. The number of hospital beds has risen steadily over the last few decades. Physical restraints are used far more often. In 2014, more than 10,000 people were restrained – the highest ever recorded (at the time), and more than double the number a decade earlier. In 2018, the Japanese Ministry of Health introduced revised guidelines that placed more restrictions against the use of restraints.

Africa

Uganda has one psychiatric hospital. There are only 40 psychiatrists in Uganda. The World Health Organisation estimates that 90% of mentally ill people here never get treatment.

New Zealand

New Zealand established a reconciliation initiative in 2005 to address the ongoing compensation payouts to ex-patients of state-run mental institutions in the 1970s to 1990s. A number of grievances were heard, including: poor reasons for admissions; unsanitary and overcrowded conditions; lack of communication to patients and family members; physical violence and sexual misconduct and abuse; inadequate mechanisms for dealing with complaints; pressures and difficulties for staff, within an authoritarian hierarchy based on containment; fear and humiliation in the misuse of seclusion; over-use and abuse of ECT, psychiatric medications, and other treatments as punishments, including group therapy, with continued adverse effects; lack of support on discharge; interrupted lives and lost potential; and continued stigma, prejudice, and emotional distress and trauma.

There were some references to instances of helpful aspects or kindnesses despite the system. Participants were offered counselling to help them deal with their experiences, along with advice on their rights, including access to records and legal redress.

Italy

Italy was the first country to begin the deinstitutionalisation of mental health care and to develop a community-based psychiatric system. The Italian system served as a model of effective service and paved the way for deinstitutionalisation of mental patients. Since the late 1960s, the Italian physician Giorgio Antonucci questioned the basis itself of psychiatry. After working with Edelweiss Cotti in 1968 at the Centro di Relazioni Umane in Cividale del Friuli – an open ward created as an alternative to the psychiatric hospital – from 1973 to 1996 Antonucci worked on the dismantling of the psychiatric hospitals Osservanza and Luigi Lolli of Imola and the liberation – and restitution to life – of the people there secluded. In 1978, the Basaglia Law had started Italian psychiatric reform that resulted in the end of the Italian state mental hospital system in 1998.

The reform was focused on the gradual dismantlement of psychiatric hospitals, which required an effective community mental health service. The object of community care was to reverse the long-accepted practice of isolating the mentally ill in large institutions and to promote their integration in a socially stimulating environment, while avoiding subjecting them to excessive social pressures.

The work of Giorgio Antonucci, instead of changing the form of commitment from the mental hospital to other forms of coercion, questions the basis of psychiatry, affirming that mental hospitals are the essence of psychiatry and rejecting any possible reform of psychiatry, that must be completely eliminated.

United Kingdom

In the United Kingdom, the trend towards deinstitutionalisation began in the 1950s. At the time, 0.4% of the population of England were housed in asylums. The government of Harold Macmillan sponsored the Mental Health Act 1959, which removed the distinction between psychiatric hospitals and other types of hospitals. Enoch Powell, the Minister of Health in the early 1960s, criticised psychiatric institutions in his 1961 “Water Tower” speech and called for most of the care to be transferred to general hospitals and the community. The campaigns of Barbara Robb and several scandals involving mistreatment at asylums (notably Ely Hospital) furthered the campaign. The Ely Hospital scandal led to an inquiry led by Brian Abel-Smith and a 1971 white paper that recommended further reform.

The policy of deinstitutionalisation came to be known as Care in the Community at the time it was taken up by the government of Margaret Thatcher. Large-scale closures of the old asylums began in the 1980s. By 2015, none remained.

United States

The United States has experienced two main waves of deinstitutionalisation. The first wave began in the 1950s and targeted people with mental illness. The second wave began roughly 15 years later and focused on individuals who had been diagnosed with a developmental disability. Loren Mosher argues that deinstitutionalisation fully began in the 1970s and was due to financial incentives like SSI and Social Security Disability, rather than after the earlier introduction of psychiatric drugs.

The most important factors that led to deinstitutionalisation were changing public attitudes to mental health and mental hospitals, the introduction of psychiatric drugs and individual states’ desires to reduce costs from mental hospitals. The federal government offered financial incentives to the states to achieve this goal. Stroman pinpoints World War II as the point when attitudes began to change. In 1946, Life magazine published one of the first exposés of the shortcomings of mental illness treatment. Also in 1946, Congress passed the National Mental Health Act of 1946, which created the National Institute of Mental Health (NIMH). NIMH was pivotal in funding research for the developing mental health field.

President John F. Kennedy had a special interest in the issue of mental health because his sister, Rosemary, had incurred brain damage after being lobotomised at the age of 23. His administration sponsored the successful passage of the Community Mental Health Act, one of the most important laws that led to deinstitutionalisation. The movement continued to gain momentum during the Civil Rights Movement. The 1965 amendments to Social Security shifted about 50% of the mental health care costs from states to the federal government, motivating state governments to promote deinstitutionalization. The 1970s saw the founding of several advocacy groups, including Liberation of Mental Patients, Project Release, Insane Liberation Front, and the National Alliance on Mental Illness (NAMI).

The lawsuits these activist groups filed led to some key court rulings in the 1970s that increased the rights of patients. In 1973, a federal district court ruled in Souder v. Brennan that whenever patients in mental health institutions performed activity that conferred an economic benefit to an institution, they had to be considered employees and paid the minimum wage required by the Fair Labour Standards Act of 1938. Following this ruling, institutional peonage was outlawed. In the 1975 ruling O’Connor v. Donaldson, the US Supreme Court restricted the rights of states to incarcerate someone who was not violent. This was followed up with the 1978 ruling Addington v. Texas, further restricting states from confining anyone involuntarily for mental illness. In 1975, the United States Court of Appeals for the First Circuit ruled in favour of the Mental Patient’s Liberation Front in Rogers v. Okin, establishing the right of a patient to refuse treatment. Later reforms included the Mental Health Parity Act, which required health insurers to give mental health patients equal coverage.

Other factors included scandals. A 1972 television broadcast exposed the abuse and neglect of 5,000 patients at the Willowbrook State School in Staten Island, New York. The Rosenhan’s experiment in 1973 caused several psychiatric hospitals to fail to notice fake patients who showed no symptoms once they were institutionalised. The pitfalls of institutionalisation were dramatised in an award-winning 1975 film, One Flew Over the Cuckoo’s Nest.

In 1955, for every 100,000 US citizens there were 340 psychiatric hospital beds. In 2005 that number had diminished to 17 per 100,000.

South America

In several South American countries, such as in Argentina, the total number of beds in asylum-type institutions has decreased, replaced by psychiatric inpatient units in general hospitals and other local settings.

In Brazil, there are 6003 psychiatrists, 18,763 psychologists, 1985 social workers, 3119 nurses and 3589 occupational therapists working for the Unified Health System (SUS). At primary care level, there are 104,789 doctors, 184,437 nurses and nurse technicians and 210,887 health agents. The number of psychiatrists is roughly 5 per 100,000 inhabitants in the Southeast region, and the Northeast region has less than 1 psychiatrist per 100,000 inhabitants. The number of psychiatric nurses is insufficient in all geographical areas, and psychologists outnumber other mental health professionals in all regions of the country. The rate of beds in psychiatric hospitals in the country is 27.17 beds per 100,000 inhabitants. The rate of patients in psychiatric hospitals is 119 per 100,000 inhabitants. The average length of stay in mental hospitals is 65.29 days.

Linking Depression & Internet Gaming Disorder

Published on by Andrew Marshall1 Comment

Research Paper Title

Depressive symptoms and depression in individuals with internet gaming disorder: A systematic review and meta-analysis.

Background

Although depression has frequently been associated with Internet Gaming Disorder (IGD), its epidemiological impact on this emerging condition has not been systematically assessed. In this study, the researchers aimed to synthesize the available evidence focusing on depression and depressive symptoms in individuals with IGD.

Methods

The researchers searched PubMed, Embase, PsycINFO, GreyLit, OpenGrey, and ProQuest up to March 2020 for observational studies focusing on depression-related outcomes in IGD. They conducted random-effects meta-analyses on 1) rate of comorbid depression in IGD; 2) severity of depressive symptoms in IGD participants without depression.

Results

The researchers identified 92 studies from 25 different countries including 15,148 participants. 21 studies (n = 5025 participants) provided data for the first analysis, resulting in a pooled event rate of depression of 0.32 (95% Confidence Interval 0.21-0.43). The pooled Beck Depression Inventory scores in individuals without depression were suggestive of mild severity (13 studies, n = 508; 10.3, 95% Confidence Interval 8.3-12.4).

Conclusions

The considerable inconsistency of methods employed across studies limits the transferability of these findings to clinical practice.

The prevalence of depression in individuals with IGD varied considerably across studies, affecting approximately one out of three participants overall. Furthermore, a globally major severity of depressive symptoms was found in those without a clinical diagnosis of depression, compared to the general population.

These findings confirm a relevant impact of mood disturbances in IGD.

Reference

Ostinelli, E.G., Zangani, C., Giordano, B., Maestri, D., Gambini, O., D’Agostino, A., Furukawa, T.A. & Purgato, M. (2021) Depressive symptoms and depression in individuals with internet gaming disorder: A systematic review and meta-analysis. Journal of Affective Disorders. doi: 10.1016/j.jad.2021.02.014. Online ahead of print.

What is Cognitive Behavioural Therapy?

Published on by Andrew Marshall46 Comments

Introduction

Cognitive behavioural therapy (CBT) is a psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing unhelpful cognitive distortions (e.g. thoughts, beliefs, and attitudes) and behaviours, improving emotional regulation, and the development of personal coping strategies that target solving current problems. Originally, it was designed to treat depression, but its uses have been expanded to include treatment of a number of mental health conditions, including anxiety. CBT includes a number of cognitive or behaviour psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

CBT is based on the combination of the basic principles from behavioural and cognitive psychology. It is different from historical approaches to psychotherapy, such as the psychoanalytic approach where the therapist looks for the unconscious meaning behind the behaviours and then formulates a diagnosis. Instead, CBT is a “problem-focused” and “action-oriented” form of therapy, meaning it is used to treat specific problems related to a diagnosed mental disorder. The therapist’s role is to assist the client in finding and practicing effective strategies to address the identified goals and decrease symptoms of the disorder. CBT is based on the belief that thought distortions and maladaptive behaviours play a role in the development and maintenance of psychological disorders, and that symptoms and associated distress can be reduced by teaching new information-processing skills and coping mechanisms.

When compared to psychoactive medications, review studies have found CBT alone to be as effective for treating less severe forms of depression, anxiety, post traumatic stress disorder (PTSD), tics, substance abuse, eating disorders and borderline personality disorder. Some research suggests that CBT is most effective when combined with medication for treating mental disorders such as major depressive disorder. In addition, CBT is recommended as the first line of treatment for the majority of psychological disorders in children and adolescents, including aggression and conduct disorder. Researchers have found that other bona fide therapeutic interventions were equally effective for treating certain conditions in adults. Along with interpersonal psychotherapy (IPT), CBT is recommended in treatment guidelines as a psychosocial treatment of choice. Psychiatry residents in the United States are mandated to receive training in psychodynamic, cognitive-behavioural, and supportive psychotherapy.

Brief History

Philosophical Roots

Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly Stoicism. Stoic philosophers, particularly Epictetus, believed logic could be used to identify and discard false beliefs that lead to destructive emotions, which has influenced the way modern cognitive-behavioural therapists identify cognitive distortions that contribute to depression and anxiety. For example, Aaron T. Beck’s original treatment manual for depression states, “The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers”. Another example of Stoic influence on cognitive theorists is Epictetus on Albert Ellis. A key philosophical figure who also influenced the development of CBT was John Stuart Mill.

Behaviour Therapy Roots

The modern roots of CBT can be traced to the development of behaviour therapy in the early 20th century, the development of cognitive therapy in the 1960s, and the subsequent merging of the two. Groundbreaking work of behaviourism began with John B. Watson and Rosalie Rayner’s studies of conditioning in 1920. Behaviourally-centred therapeutic approaches appeared as early as 1924 with Mary Cover Jones’ work dedicated to the unlearning of fears in children. These were the antecedents of the development of Joseph Wolpe’s behavioural therapy in the 1950s. It was the work of Wolpe and Watson, which was based on Ivan Pavlov’s work on learning and conditioning, that influenced Hans Eysenck and Arnold Lazarus to develop new behavioural therapy techniques based on classical conditioning.

During the 1950s and 1960s, behavioural therapy became widely utilised by researchers in the United States, the United Kingdom, and South Africa, who were inspired by the behaviourist learning theory of Ivan Pavlov, John B. Watson, and Clark L. Hull. In Britain, Joseph Wolpe, who applied the findings of animal experiments to his method of systematic desensitisation, applied behavioural research to the treatment of neurotic disorders. Wolpe’s therapeutic efforts were precursors to today’s fear reduction techniques. British psychologist Hans Eysenck presented behaviour therapy as a constructive alternative.

At the same time as Eysenck’s work, B. F. Skinner and his associates were beginning to have an impact with their work on operant conditioning. Skinner’s work was referred to as radical behaviourism and avoided anything related to cognition. However, Julian Rotter, in 1954, and Albert Bandura, in 1969, contributed behaviour therapy with their respective work on social learning theory, by demonstrating the effects of cognition on learning and behaviour modification. The work of the Australian Claire Weekes dealing with anxiety disorders in the 1960s was also seen as a prototype of behaviour therapy.

The emphasis on behavioural factors constituted the “first wave” of CBT.

Cognitive Therapy Roots

One of the first therapists to address cognition in psychotherapy was Alfred Adler with his notion of basic mistakes and how they contributed to creation of unhealthy or useless behavioural and life goals. Adler’s work influenced the work of Albert Ellis, who developed the earliest cognitive-based psychotherapy, known today as rational emotive behaviour therapy (REBT). Ellis also credits Abraham Low as a founder of cognitive behavioural therapy.

Around the same time that rational emotive therapy, as it was known then, was being developed, Aaron T. Beck was conducting free association sessions in his psychoanalytic practice. During these sessions, Beck noticed that thoughts were not as unconscious as Freud had previously theorised, and that certain types of thinking may be the culprits of emotional distress. It was from this hypothesis that Beck developed cognitive therapy, and called these thoughts “automatic thoughts”. Beck has been referred to as “the father of cognitive behavioural therapy.”

It was these two therapies, rational emotive therapy and cognitive therapy, that started the “second wave” of CBT, which was the emphasis on cognitive factors.

Behaviour and Cognitive Therapies Merge – “Third Wave” CBT

Although the early behavioural approaches were successful in many of the neurotic disorders, they had little success in treating depression. Behaviourism was also losing in popularity due to the so-called “cognitive revolution”. The therapeutic approaches of Albert Ellis and Aaron T. Beck gained popularity among behaviour therapists, despite the earlier behaviourist rejection of “mentalistic” concepts like thoughts and cognitions. Both of these systems included behavioural elements and interventions and primarily concentrated on problems in the present.

In initial studies, cognitive therapy was often contrasted with behavioural treatments to see which was most effective. During the 1980s and 1990s, cognitive and behavioural techniques were merged into cognitive behavioural therapy. Pivotal to this merging was the successful development of treatments for panic disorder by David M. Clark in the UK and David H. Barlow in the US.

Over time, cognitive behaviour therapy came to be known not only as a therapy, but as an umbrella term for all cognitive-based psychotherapies. These therapies include, but are not limited to, rational emotive therapy (RET), cognitive therapy, acceptance and commitment therapy, dialectical behaviour therapy, metacognitive therapy, metacognitive training, reality therapy/choice theory, cognitive processing therapy, EMDR, and multimodal therapy. All of these therapies are a blending of cognitive- and behaviour-based elements.

This blending of theoretical and technical foundations from both behaviour and cognitive therapies constituted the “third wave” of CBT. The most prominent therapies of this third wave are dialectical behaviour therapy and acceptance and commitment therapy.

Despite increasing popularity of “third-wave” treatment approaches, reviews of studies reveal there may be no difference in the effectiveness compared with “non-third wave” CBT for the treatment of depression.

Description

Mainstream cognitive behavioural therapy assumes that changing maladaptive thinking leads to change in behaviour and affect, but recent variants emphasize changes in one’s relationship to maladaptive thinking rather than changes in thinking itself. The goal of cognitive behavioural therapy is not to diagnose a person with a particular disease, but to look at the person as a whole and decide what can be altered.

Cognitive Distortions

Therapists or computer-based programmes use CBT techniques to help people challenge their patterns and beliefs and replace errors in thinking, known as cognitive distortions, such as “overgeneralising, magnifying negatives, minimising positives and catastrophising” with “more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behaviour”. Cognitive distortions can be either a pseudo-discrimination belief or an over-generalisation of something. CBT techniques may also be used to help individuals take a more open, mindful, and aware posture toward cognitive distortions so as to diminish their impact.

Skills

Mainstream CBT helps individuals replace “maladaptive… coping skills, cognitions, emotions and behaviours with more adaptive ones”, by challenging an individual’s way of thinking and the way that they react to certain habits or behaviours, but there is still controversy about the degree to which these traditional cognitive elements account for the effects seen with CBT over and above the earlier behavioural elements such as exposure and skills training.

Phases in Therapy

CBT can be seen as having six phases:

  1. Assessment or psychological assessment;
  2. Reconceptualisation;
  3. Skills acquisition;
  4. Skills consolidation and application training;
  5. Generalisation and maintenance;
  6. Post-treatment assessment follow-up.

These steps are based on a system created by Kanfer and Saslow. After identifying the behaviours that need changing, whether they be in excess or deficit, and treatment has occurred, the psychologist must identify whether or not the intervention succeeded. For example, “If the goal was to decrease the behaviour, then there should be a decrease relative to the baseline. If the critical behaviour remains at or above the baseline, then the intervention has failed.”

The steps in the assessment phase include:

  • Step 1: Identify critical behaviours.
  • Step 2: Determine whether critical behaviours are excesses or deficits.
  • Step 3: Evaluate critical behaviours for frequency, duration, or intensity (obtain a baseline).
  • Step 4: If excess, attempt to decrease frequency, duration, or intensity of behaviours; if deficits, attempt to increase behaviours.

The re-conceptualisation phase makes up much of the “cognitive” portion of CBT. A summary of modern CBT approaches is given by Hofmann.

Delivery Protocols

There are different protocols for delivering cognitive behavioural therapy, with important similarities among them. Use of the term CBT may refer to different interventions, including “self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (e.g. minimising negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting”. Treatment is sometimes manualised, with brief, direct, and time-limited treatments for individual psychological disorders that are specific technique-driven. CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are cognitively oriented (e.g. cognitive restructuring), while others are more behaviourally oriented (e.g. in vivo exposure therapy). Interventions such as imaginal exposure therapy combine both approaches.

Related Techniques

CBT may be delivered in conjunction with a variety of diverse but related techniques such as exposure therapy, stress inoculation, cognitive processing therapy, cognitive therapy, metacognitive therapy, metacognitive training, relaxation training, dialectical behaviour therapy, and acceptance and commitment therapy. Some practitioners promote a form of mindful cognitive therapy which includes a greater emphasis on self-awareness as part of the therapeutic process.

Medical Application

In adults, CBT has been shown to have effectiveness and a role in the treatment plans for anxiety disorders, body dysmorphic disorder, depression, eating disorders, chronic low back pain, personality disorders, psychosis, schizophrenia, substance use disorders, in the adjustment, depression, and anxiety associated with fibromyalgia, and with post-spinal cord injuries.

In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders, body dysmorphic disorder, depression and suicidality, eating disorders and obesity, obsessive compulsive disorder (OCD), and posttraumatic stress disorder, as well as tic disorders, trichotillomania, and other repetitive behaviour disorders. CBT-SP, an adaptation of CBT for suicide prevention (SP), was specifically designed for treating youths who are severely depressed and who have recently attempted suicide within the past 90 days, and was found to be effective, feasible, and acceptable. CBT has also been shown to be effective for post traumatic stress disorder in very young children (3 to 6 years of age). Reviews found “low quality” evidence that CBT may be more effective than other psychotherapies in reducing symptoms of posttraumatic stress disorder in children and adolescents. CBT has also been applied to a variety of childhood disorders, including depressive disorders and various anxiety disorders.

CBT combined with hypnosis and distraction reduces self-reported pain in children.

Cochrane reviews have found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition. Other recent Cochrane Reviews found no convincing evidence that CBT training helps foster care providers manage difficult behaviours in the youths under their care,[79] nor was it helpful in treating people who abuse their intimate partners.

According to a 2004 review by INSERM of three methods, cognitive behavioural therapy was either “proven” or “presumed” to be an effective therapy on several specific mental disorders. According to the study, CBT was effective at treating schizophrenia, depression, bipolar disorder, panic disorder, post-traumatic stress, anxiety disorders, bulimia, anorexia, personality disorders and alcohol dependency.

Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression.

Computerized CBT (CCBT) has been proven to be effective by randomised controlled and other trials in treating depression and anxiety disorders, including children, as well as insomnia. Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls. CCBT was found to be equally effective as face-to-face CBT in adolescent anxiety and insomnia.

Criticism of CBT sometimes focuses on implementations (such as the UK IAPT) which may result initially in low quality therapy being offered by poorly trained practitioners. However, evidence supports the effectiveness of CBT for anxiety and depression. Acceptance and commitment therapy (ACT) is a specialist branch of CBT (sometimes referred to as contextual CBT). ACT uses mindfulness and acceptance interventions and has been found to have a greater longevity in therapeutic outcomes. In a study with anxiety, CBT and ACT improved similarly across all outcomes from pre-to post-treatment. However, during a 12-month follow-up, ACT proved to be more effective, showing that it is a highly viable lasting treatment model for anxiety disorders.

Evidence suggests that the addition of hypnotherapy as an adjunct to CBT improves treatment efficacy for a variety of clinical issues.

CBT has been applied in both clinical and non-clinical environments to treat disorders such as personality conditions and behavioural problems. A systematic review of CBT in depression and anxiety disorders concluded that “CBT delivered in primary care, especially including computer- or Internet-based self-help programmes, is potentially more effective than usual care and could be delivered effectively by primary care therapists.”

Emerging evidence suggests a possible role for CBT in the treatment of attention deficit hyperactivity disorder (ADHD); hypochondriasis; coping with the impact of multiple sclerosis; sleep disturbances related to aging; dysmenorrhea; and bipolar disorder, but more study is needed and results should be interpreted with caution. CBT can have a therapeutic effects on easing symptoms of anxiety and depression in people with Alzheimer’s disease. CBT has been studied as an aid in the treatment of anxiety associated with stuttering. Initial studies have shown CBT to be effective in reducing social anxiety in adults who stutter, but not in reducing stuttering frequency.

In the case of people with metastatic breast cancer, data is limited but CBT and other psychosocial interventions might help with psychological outcomes and pain management.

There is some evidence that CBT is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia. CBT has been shown to be moderately effective for treating chronic fatigue syndrome.

In the United Kingdom, the National Institute for Health and Care Excellence (NICE) recommends CBT in the treatment plans for a number of mental health difficulties, including posttraumatic stress disorder, obsessive compulsive disorder (OCD), bulimia nervosa, and clinical depression.

Depression

Cognitive behavioural therapy has been shown as an effective treatment for clinical depression. The American Psychiatric Association Practice Guidelines (April 2000) indicated that, among psychotherapeutic approaches, cognitive behavioural therapy and interpersonal psychotherapy had the best-documented efficacy for treatment of major depressive disorder. One etiological theory of depression is Aaron T. Beck’s cognitive theory of depression. His theory states that depressed people think the way they do because their thinking is biased towards negative interpretations. According to this theory, depressed people acquire a negative schema of the world in childhood and adolescence as an effect of stressful life events, and the negative schema is activated later in life when the person encounters similar situations.

Beck also described a negative cognitive triad. The cognitive triad is made up of the depressed individual’s negative evaluations of themselves, the world, and the future. Beck suggested that these negative evaluations derive from the negative schemata and cognitive biases of the person. According to this theory, depressed people have views such as “I never do a good job”, “It is impossible to have a good day”, and “things will never get better”. A negative schema helps give rise to the cognitive bias, and the cognitive bias helps fuel the negative schema. Beck further proposed that depressed people often have the following cognitive biases: arbitrary inference, selective abstraction, over-generalisation, magnification, and minimisation. These cognitive biases are quick to make negative, generalised, and personal inferences of the self, thus fuelling the negative schema.

A 2001 meta-analysis comparing CBT and psychodynamic psychotherapy suggested the approaches were equally effective in the short term. In contrast, a 2013 meta-analyses suggested that CBT, interpersonal therapy, and problem-solving therapy outperformed psychodynamic psychotherapy and behavioural activation in the treatment of depression.

Anxiety Disorders

CBT has been shown to be effective in the treatment of adults with anxiety disorders. A basic concept in some CBT treatments used in anxiety disorders is in vivo exposure. CBT-exposure therapy refers to the direct confrontation of feared objects, activities, or situations by a patient. Results from a 2018 systematic review found a high strength of evidence that CBT-exposure therapy can reduce PTSD symptoms and lead to the loss of a PTSD diagnosis.

For example, a woman with PTSD who fears the location where she was assaulted may be assisted by her therapist in going to that location and directly confronting those fears. Likewise, a person with social anxiety disorder who fears public speaking may be instructed to directly confront those fears by giving a speech. This “two-factor” model is often credited to O. Hobart Mowrer. Through exposure to the stimulus, this harmful conditioning can be “unlearned” (referred to as extinction and habituation). Studies have provided evidence that when examining animals and humans that glucocorticoids may possibly lead to a more successful extinction learning during exposure therapy. For instance, glucocorticoids can prevent aversive learning episodes from being retrieved and heighten reinforcement of memory traces creating a non-fearful reaction in feared situations. A combination of glucocorticoids and exposure therapy may be a better improved treatment for treating patients with anxiety disorders.

A 2015 Cochrane review also found that CBT for symptomatic management of non-specific chest pain is probably effective in the short term. However, the findings were limited by small trials and the evidence was considered of questionable quality.

Bipolar Disorder

Many studies show CBT, combined with pharmacotherapy, is effective on improving depressive symptoms, mania severity and psychosocial functioning with mild to moderate effects, and that it is better than medication alone.

Psychosis

In long-term psychoses, CBT is used to complement medication and is adapted to meet individual needs. Interventions particularly related to these conditions include exploring reality testing, changing delusions and hallucinations, examining factors which precipitate relapse, and managing relapses. Meta-analyses confirm the effectiveness of metacognitive training (MCT) for the improvement of positive symptoms (e.g., delusions).

Schizophrenia

A Cochrane review reported CBT had “no effect on long‐term risk of relapse” and no additional effect above standard care. A 2015 systematic review investigated the effects of CBT compared with other psychosocial therapies for people with schizophrenia and determined that there is no clear advantage over other, often less expensive, interventions but acknowledged that better quality evidence is needed before firm conclusions can be drawn.

With Older Adults

CBT is used to help people of all ages, but the therapy should be adjusted based on the age of the patient with whom the therapist is dealing. Older individuals in particular have certain characteristics that need to be acknowledged and the therapy altered to account for these differences thanks to age. Of the small number of studies examining CBT for the management of depression in older people, there is currently no strong support.

Prevention of Mental Illness

For anxiety disorders, use of CBT with people at risk has significantly reduced the number of episodes of generalised anxiety disorder and other anxiety symptoms, and also given significant improvements in explanatory style, hopelessness, and dysfunctional attitudes. In another study, 3% of the group receiving the CBT intervention developed generalised anxiety disorder by 12 months postintervention compared with 14% in the control group. Subthreshold panic disorder sufferers were found to significantly benefit from use of CBT. Use of CBT was found to significantly reduce social anxiety prevalence.

For depressive disorders, a stepped-care intervention (watchful waiting, CBT and medication if appropriate) achieved a 50% lower incidence rate in a patient group aged 75 or older. Another depression study found a neutral effect compared to personal, social, and health education, and usual school provision, and included a comment on potential for increased depression scores from people who have received CBT due to greater self recognition and acknowledgement of existing symptoms of depression and negative thinking styles. A further study also saw a neutral result. A meta-study of the Coping with Depression course, a cognitive behavioural intervention delivered by a psychoeducational method, saw a 38% reduction in risk of major depression.

For people at risk of psychosis, in 2014 the UK National Institute for Health and Care Excellence (NICE) recommended preventive CBT.

Pathological and Problem Gambling

CBT is also used for pathological and problem gambling. The percentage of people who problem gamble is 1-3% around the world. Cognitive behavioural therapy develops skills for relapse prevention and someone can learn to control their mind and manage high-risk cases. There is evidence of efficacy of CBT for treating pathological and problem gambling at immediate follow up, however the longer term efficacy of CBT for it is currently unknown.

Smoking Cessation

CBT looks at the habit of smoking cigarettes as a learned behaviour, which later evolves into a coping strategy to handle daily stressors. Because smoking is often easily accessible, and quickly allows the user to feel good, it can take precedence over other coping strategies, and eventually work its way into everyday life during non-stressful events as well. CBT aims to target the function of the behaviour, as it can vary between individuals, and works to inject other coping mechanisms in place of smoking. CBT also aims to support individuals suffering from strong cravings, which are a major reported reason for relapse during treatment.

In a 2008 controlled study out of Stanford University School of Medicine, suggested CBT may be an effective tool to help maintain abstinence. The results of 304 random adult participants were tracked over the course of one year. During this program, some participants were provided medication, CBT, 24 hour phone support, or some combination of the three methods. At 20 weeks, the participants who received CBT had a 45% abstinence rate, versus non-CBT participants, who had a 29% abstinence rate. Overall, the study concluded that emphasizing cognitive and behavioural strategies to support smoking cessation can help individuals build tools for long term smoking abstinence.

Mental health history can affect the outcomes of treatment. Individuals with a history of depressive disorders had a lower rate of success when using CBT alone to combat smoking addiction.

A Cochrane review was unable to find evidence of any difference between CBT and hypnosis for smoking cessation. While this may be evidence of no effect, further research may uncover an effect of CBT for smoking cessation.

Substance Abuse Disorders

Studies have shown CBT to be an effective treatment for substance abuse. For individuals with substance abuse disorders, CBT aims to reframe maladaptive thoughts, such as denial, minimising and catastrophising thought patterns, with healthier narratives. Specific techniques include identifying potential triggers and developing coping mechanisms to manage high-risk situations. Research has shown CBT to be particularly effective when combined with other therapy-based treatments or medication.

Eating Disorders

Though many forms of treatment can support individuals with eating disorders, CBT is proven to be a more effective treatment than medications and interpersonal psychotherapy alone. CBT aims to combat major causes of distress such as negative cognitions surrounding body weight, shape and size. CBT therapists also work with individuals to regulate strong emotions and thoughts that lead to dangerous compensatory behaviours. CBT is the first line of treatment for Bulimia Nervosa, and Eating Disorder Non-Specific. While there is evidence to support the efficacy of CBT for bulimia nervosa and binging, the evidence is somewhat variable and limited by small study sizes.

Internet Addiction

Research has identified Internet addiction as a new clinical disorder that causes relational, occupational, and social problems. Cognitive behavioural therapy (CBT) has been suggested as the treatment of choice for Internet addiction, and addiction recovery in general has used CBT as part of treatment planning.

Prevention of Occupational Stress

A Cochrane review of interventions aimed at preventing psychological stress in healthcare workers found that CBT was more effective than no intervention but no more effective than alternative stress-reduction interventions.

With Autistic Adults

Emerging evidence for cognitive behavioural interventions aimed at reducing symptoms of depression, anxiety, and obsessive-compulsive disorder in autistic adults without intellectual disability has been identified through a systematic review. While the research was focused on adults, cognitive behavioural interventions have also been beneficial to autistic children.

Access and Delivery of CBT

Therapist

A typical CBT programme would consist of face-to-face sessions between patient and therapist, made up of 6-18 sessions of around an hour each with a gap of 1-3 weeks between sessions. This initial programme might be followed by some booster sessions, for instance after one month and three months. CBT has also been found to be effective if patient and therapist type in real time to each other over computer links.

Cognitive behavioural therapy is most closely allied with the scientist-practitioner model in which clinical practice and research is informed by a scientific perspective, clear operationalisation of the problem, and an emphasis on measurement, including measuring changes in cognition and behaviour and in the attainment of goals. These are often met through “homework” assignments in which the patient and the therapist work together to craft an assignment to complete before the next session. The completion of these assignments – which can be as simple as a person suffering from depression attending some kind of social event – indicates a dedication to treatment compliance and a desire to change. The therapists can then logically gauge the next step of treatment based on how thoroughly the patient completes the assignment. Effective cognitive behavioural therapy is dependent on a therapeutic alliance between the healthcare practitioner and the person seeking assistance. Unlike many other forms of psychotherapy, the patient is very involved in CBT. For example, an anxious patient may be asked to talk to a stranger as a homework assignment, but if that is too difficult, he or she can work out an easier assignment first. The therapist needs to be flexible and willing to listen to the patient rather than acting as an authority figure.

Computerised or Internet-Delivered

Although computerised cognitive behavioural therapy (CCBT) has been a topic of sustained controversy, it has been described by NICE as a “generic term for delivering CBT via an interactive computer interface delivered by a personal computer, internet, or interactive voice response system”, instead of face-to-face with a human therapist. It is also known as internet-delivered cognitive behavioural therapy (ICBT). CCBT has potential to improve access to evidence-based therapies, and to overcome the prohibitive costs and lack of availability sometimes associated with retaining a human therapist. In this context, it is important not to confuse CBT with ‘computer-based training’, which nowadays is more commonly referred to as e-Learning.

CCBT has been found in meta-studies to be cost-effective and often cheaper than usual care, including for anxiety. Studies have shown that individuals with social anxiety and depression experienced improvement with online CBT-based methods. A review of current CCBT research in the treatment of OCD in children found this interface to hold great potential for future treatment of OCD in youths and adolescent populations. Additionally, most internet interventions for posttraumatic stress disorder use CCBT. CCBT is also predisposed to treating mood disorders amongst non-heterosexual populations, who may avoid face-to-face therapy from fear of stigma. However presently CCBT programmes seldom cater to these populations.

A key issue in CCBT use is low uptake and completion rates, even when it has been clearly made available and explained. CCBT completion rates and treatment efficacy have been found in some studies to be higher when use of CCBT is supported personally, with supporters not limited only to therapists, than when use is in a self-help form alone. Another approach to improving the uptake and completion rate, as well as the treatment outcome, is to design software that supports the formation of a strong therapeutic alliance between the user and the technology.

In February 2006 NICE recommended that CCBT be made available for use within the NHS across England and Wales for patients presenting with mild-to-moderate depression, rather than immediately opting for antidepressant medication, and CCBT is made available by some health systems. The 2009 NICE guideline recognised that there are likely to be a number of computerized CBT products that are useful to patients, but removed endorsement of any specific product.

A relatively new avenue of research is the combination of artificial intelligence and CCBT. It has been proposed to use modern technology to create CCBT that simulates face-to-face therapy. This might be achieved in cognitive behaviour therapy for a specific disorder using the comprehensive domain knowledge of CBT. One area where this has been attempted is the specific domain area of social anxiety in those who stutter.

Smartphone App-Delivered

Another new method of access is the use of mobile app or smartphone applications to deliver self-help or guided CBT. Technology companies are developing mobile-based artificial intelligence chatbot applications in delivering CBT as an early intervention to support mental health, to build psychological resilience and to promote emotional well-being. Artificial intelligence (AI) text-based conversational application delivered securely and privately over smartphone devices have the ability to scale globally and offer contextual and always-available support. Active research is underway including real world data studies that measure effectiveness and engagement of text-based smartphone chatbot apps for delivery of CBT using a text-based conversational interface.

Reading Self-Help Materials

Enabling patients to read self-help CBT guides has been shown to be effective by some studies. However one study found a negative effect in patients who tended to ruminate, and another meta-analysis found that the benefit was only significant when the self-help was guided (e.g. by a medical professional).

Group Educational Course

Patient participation in group courses has been shown to be effective. In a meta-analysis reviewing evidence-based treatment of OCD in children, individual CBT was found to be more efficacious than group CBT.

Types

BCBT

Brief cognitive behavioural therapy (BCBT) is a form of CBT which has been developed for situations in which there are time constraints on the therapy sessions. BCBT takes place over a couple of sessions that can last up to 12 accumulated hours by design. This technique was first implemented and developed on soldiers overseas in active duty by David M. Rudd to prevent suicide. Breakdown of treatment:

  • Orientation:
    • Commitment to treatment.
    • Crisis response and safety planning.
    • Means restriction.
    • Survival kit.
    • Reasons for living card.
    • Model of suicidality.
    • Treatment journal.
    • Lessons learned.
  • Skill focus:
    • Skill development worksheets.
    • Coping cards.
    • Demonstration.
    • Practice.
    • Skill refinement.
  • Relapse prevention:
    • Skill generalisation.
    • Skill refinement.

Cognitive Emotional Behavioural Therapy

Cognitive emotional behavioural therapy (CEBT) is a form of CBT developed initially for individuals with eating disorders but now used with a range of problems including anxiety, depression, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and anger problems. It combines aspects of CBT and dialectical behavioural therapy and aims to improve understanding and tolerance of emotions in order to facilitate the therapeutic process. It is frequently used as a “pre-treatment” to prepare and better equip individuals for longer-term therapy.

Structured Cognitive Behavioural Training

Structured cognitive behavioural training (SCBT) is a cognitive-based process with core philosophies that draw heavily from CBT. Like CBT, SCBT asserts that behaviour is inextricably related to beliefs, thoughts and emotions. SCBT also builds on core CBT philosophy by incorporating other well-known modalities in the fields of behavioural health and psychology: most notably, Albert Ellis’s rational emotive behaviour therapy. SCBT differs from CBT in two distinct ways. First, SCBT is delivered in a highly regimented format. Second, SCBT is a predetermined and finite training process that becomes personalized by the input of the participant. SCBT is designed with the intention to bring a participant to a specific result in a specific period of time. SCBT has been used to challenge addictive behaviour, particularly with substances such as tobacco, alcohol and food, and to manage diabetes and subdue stress and anxiety. SCBT has also been used in the field of criminal psychology in the effort to reduce recidivism.

Moral Reconation Therapy

Moral reconation therapy, a type of CBT used to help felons overcome antisocial personality disorder (ASPD), slightly decreases the risk of further offending. It is generally implemented in a group format because of the risk of offenders with ASPD being given one-on-one therapy reinforces narcissistic behavioural characteristics, and can be used in correctional or outpatient settings. Groups usually meet weekly for two to six months.

Stress Inoculation Training

This type of therapy uses a blend of cognitive, behavioural and some humanistic training techniques to target the stressors of the client. This usually is used to help clients better cope with their stress or anxiety after stressful events. This is a three-phase process that trains the client to use skills that they already have to better adapt to their current stressors. The first phase is an interview phase that includes psychological testing, client self-monitoring, and a variety of reading materials. This allows the therapist to individually tailor the training process to the client. Clients learn how to categorize problems into emotion-focused or problem-focused, so that they can better treat their negative situations. This phase ultimately prepares the client to eventually confront and reflect upon their current reactions to stressors, before looking at ways to change their reactions and emotions in relation to their stressors. The focus is conceptualisation.

The second phase emphasizes the aspect of skills acquisition and rehearsal that continues from the earlier phase of conceptualisation. The client is taught skills that help them cope with their stressors. These skills are then practised in the space of therapy. These skills involve self-regulation, problem-solving, interpersonal communication skills, etc.

The third and final phase is the application and following through of the skills learned in the training process. This gives the client opportunities to apply their learned skills to a wide range of stressors. Activities include role-playing, imagery, modelling, etc. In the end, the client will have been trained on a preventive basis to inoculate personal, chronic, and future stressors by breaking down their stressors into problems they will address in long-term, short-term, and intermediate coping goals.

Activity-Guided CBT: Group-Knitting

A newly developed group therapy model based on Cognitive Behavioural Therapy (CBT) integrates knitting into the therapeutic process and has been proven to yield reliable and promising results. The foundation for this novel approach to CBT is the frequently emphasized notion that therapy success depends on the embeddedness of the therapy method in the patients’ natural routine. Similar to standard group-based Cognitive Behavioural Therapy, patients meet once a week in a group of 10 to 15 patients and knit together under the instruction of a trained psychologist or mental health professional. Central for the therapy is the patient’s imaginative ability to assign each part of the wool to a certain thought. During the therapy, the wool is carefully knitted, creating a knitted piece of any form. This therapeutic process teaches the patient to meaningfully align thought, by (physically) creating a coherent knitted piece. Moreover, since CBT emphasizes the behaviour as a result of cognition, the knitting illustrates how thoughts (which are tried to be imaginary tight to the wool) materialise into the reality surrounding us.

Mindfulness-Based Cognitive Behavioural Hypnotherapy

Mindfulness-based cognitive behavioural hypnotherapy (MCBH) is a form of CBT focusing on awareness in reflective approach with addressing of subconscious tendencies. It is more the process that contains basically three phases that are used for achieving wanted goals.

Unified Protocol

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is a form of CBT, developed by David H. Barlow and researchers at Boston University, that can be applied to a range of depression and anxiety disorders. The rationale is that anxiety and depression disorders often occur together due to common underlying causes and can efficiently be treated together.

The UP includes a common set of components:

  • Psycho-education.
  • Cognitive reappraisal.
  • Emotion regulation.
  • Changing behaviour.

The UP has been shown to produce equivalent results to single-diagnosis protocols for specific disorders, such as OCD and social anxiety disorder. Several studies have shown that the UP is easier to disseminate as compared to single-diagnosis protocols.

Criticisms

Relative Effectiveness

The research conducted for CBT has been a topic of sustained controversy. While some researchers write that CBT is more effective than other treatments, many other researchers and practitioners have questioned the validity of such claims. For example, one study determined CBT to be superior to other treatments in treating anxiety and depression. However, researchers responding directly to that study conducted a re-analysis and found no evidence of CBT being superior to other bona fide treatments, and conducted an analysis of thirteen other CBT clinical trials and determined that they failed to provide evidence of CBT superiority. In cases where CBT has been reported to be statistically better than other psychological interventions in terms of primary outcome measures, effect sizes were small and suggested that those differences were clinically meaningless and insignificant. Moreover, on secondary outcomes (i.e. measures of general functioning) no significant differences have been typically found between CBT and other treatments.

A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e. either the subjects or the therapists in psychotherapy studies are not blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in.

The importance of double-blinding was shown in a meta-analysis that examined the effectiveness of CBT when placebo control and blindedness were factored in. Pooled data from published trials of CBT in schizophrenia, major depressive disorder (MDD), and bipolar disorder that used controls for non-specific effects of intervention were analysed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates; treatment effects are small in treatment studies of MDD, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder. For MDD, the authors note that the pooled effect size was very low. Nevertheless, the methodological processes used to select the studies in the previously mentioned meta-analysis and the worth of its findings have been called into question.

Declining Effectiveness

Additionally, a 2015 meta-analysis revealed that the positive effects of CBT on depression have been declining since 1977. The overall results showed two different declines in effect sizes: 1) an overall decline between 1977 and 2014, and 2) a steeper decline between 1995 and 2014. Additional sub-analysis revealed that CBT studies where therapists in the test group were instructed to adhere to the Beck CBT manual had a steeper decline in effect sizes since 1977 than studies where therapists in the test group were instructed to use CBT without a manual. The authors reported that they were unsure why the effects were declining but did list inadequate therapist training, failure to adhere to a manual, lack of therapist experience, and patients’ hope and faith in its efficacy waning as potential reasons. The authors did mention that the current study was limited to depressive disorders only.

High Drop-Out Rates

Furthermore, other researchers write that CBT studies have high drop-out rates compared to other treatments. CBT drop out rates were found to be 17% higher than other therapies in one meta-analysis. This high drop-out rate is also evident in the treatment of several disorders, particularly the eating disorder anorexia nervosa, which is commonly treated with CBT. Those treated with CBT have a high chance of dropping out of therapy before completion and reverting to their anorexia behaviours.

Other researchers conducting an analysis of treatments for youths who self-injure found similar drop-out rates in CBT and DBT groups. In this study, the researchers analysed several clinical trials that measured the efficacy of CBT administered to youths who self-injure. The researchers concluded that none of them were found to be efficacious.

Philosophical Concerns with CBT Methods

The methods employed in CBT research have not been the only criticisms; some individuals have called its theory and therapy into question.

Slife and Williams write that one of the hidden assumptions in CBT is that of determinism, or the absence of free will. They argue that CBT holds that external stimuli from the environment enter the mind, causing different thoughts that cause emotional states: nowhere in CBT theory is agency, or free will, accounted for.

Another criticism of CBT theory, especially as applied to major depressive disorder (MDD), is that it confounds the symptoms of the disorder with its causes.

Side Effects

CBT is generally regarded as having very few if any side effects. Calls have been made by some for more appraisal of possible side effects of CBT. Many randomised trials of psychological interventions like CBT do not monitor potential harms to the patient. In contrast, randomised trials of pharmacological interventions are much more likely to take adverse effects into consideration.

However, a 2017 meta-analysis revealed that adverse events are not common in children receiving CBT and, furthermore, that CBT is associated with fewer dropouts than either placebo or medications. Nevertheless, CBT therapists do sometimes report ‘unwanted events’ and side effects in their outpatients with “negative wellbeing/distress” being the most frequent.

Socio-Political Concerns

The writer and group analyst Farhad Dalal questions the socio-political assumptions behind the introduction of CBT. According to one reviewer, Dalal connects the rise of CBT with “the parallel rise of neoliberalism, with its focus on marketization, efficiency, quantification and managerialism”, and he questions the scientific basis of CBT, suggesting that “the ‘science’ of psychological treatment is often less a scientific than a political contest”. In his book, Dalal also questions the ethical basis of CBT.

Society and Culture

The UK’s National Health Service announced in 2008 that more therapists would be trained to provide CBT at government expense as part of an initiative called Improving Access to Psychological Therapies (IAPT). The NICE said that CBT would become the mainstay of treatment for non-severe depression, with medication used only in cases where CBT had failed. Therapists complained that the data does not fully support the attention and funding CBT receives. Psychotherapist and professor Andrew Samuels stated that this constitutes “a coup, a power play by a community that has suddenly found itself on the brink of corralling an enormous amount of money … Everyone has been seduced by CBT’s apparent cheapness.” The UK Council for Psychotherapy issued a press release in 2012 saying that the IAPT’s policies were undermining traditional psychotherapy and criticised proposals that would limit some approved therapies to CBT, claiming that they restricted patients to “a watered down version of cognitive behavioural therapy (CBT), often delivered by very lightly trained staff”.

The NICE also recommends offering CBT to people suffering from schizophrenia, as well as those at risk of suffering from a psychotic episode.

What is Cognitive Therapy?

Published on by Andrew Marshall11 Comments

Introduction

Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one of the therapeutic approaches within the larger group of cognitive behavioural therapies (CBT) and was first expounded by Beck in the 1960s.

CT is based on the cognitive model, which states that thoughts, feelings and behaviour are all connected, and that individuals can move toward overcoming difficulties and meeting their goals by identifying and changing unhelpful or inaccurate thinking, problematic behaviour, and distressing emotional responses. This involves the individual working collaboratively with the therapist to develop skills for testing and modifying beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviours. A tailored cognitive case conceptualisation is developed by the cognitive therapist as a roadmap to understand the individual’s internal reality, select appropriate interventions and identify areas of distress.

Brief History

Becoming disillusioned with long-term psychodynamic approaches based on gaining insight into unconscious emotions and drives, Beck came to the conclusion that the way in which his patients perceived, interpreted and attributed meaning in their daily lives – a process scientifically known as cognition – was a key to therapy. Albert Ellis had been working on similar ideas since the 1950s (Ellis, 1956). He called his approach Rational Therapy (RT) at first, then Rational Emotive Therapy (RET) and later Rational Emotive Behaviour Therapy (REBT).

Beck outlined his approach in Depression: Causes and Treatment in 1967. He later expanded his focus to include anxiety disorders, in Cognitive Therapy and the Emotional Disorders in 1976, and other disorders and problems. He also introduced a focus on the underlying “schema” – the fundamental underlying ways in which people process information – about the self, the world or the future.

The new cognitive approach came into conflict with the behaviourism ascendant at the time, which denied that talk of mental causes was scientific or meaningful, rather than simply assessing stimuli and behavioural responses. However, the 1970s saw a general “cognitive revolution” in psychology. Behavioural modification techniques and cognitive therapy techniques became joined together, giving rise to cognitive behavioural therapy. Although cognitive therapy has always included some behavioural components, advocates of Beck’s particular approach seek to maintain and establish its integrity as a distinct, clearly standardised form of cognitive behavioural therapy in which the cognitive shift is the key mechanism of change.

Precursors of certain fundamental aspects of cognitive therapy have been identified in various ancient philosophical traditions, particularly Stoicism. For example, Beck’s original treatment manual for depression states, “The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers”.

As cognitive therapy continued to grow in popularity, the Academy of Cognitive Therapy, a non-profit organisation, was created to accredit cognitive therapists, create a forum for members to share emerging research and interventions, and to educate consumer regarding cognitive therapy and related mental health issues.

Basis

Therapy may consist of testing the assumptions which one makes and looking for new information that could help shift the assumptions in a way that leads to different emotional or behavioral reactions. Change may begin by targeting thoughts (to change emotion and behavior), behavior (to change feelings and thoughts), or the individual’s goals (by identifying thoughts, feelings or behavior that conflict with the goals). Beck initially focused on depression and developed a list of “errors” (cognitive distortion) in thinking that he proposed could maintain depression, including arbitrary inference, selective abstraction, over-generalization, and magnification (of negatives) and minimization (of positives).

As an example of how CT might work: Having made a mistake at work, a man may believe, “I’m useless and can’t do anything right at work.” He may then focus on the mistake (which he takes as evidence that his belief is true), and his thoughts about being “useless” are likely to lead to negative emotion (frustration, sadness, hopelessness). Given these thoughts and feelings, he may then begin to avoid challenges at work, which is behaviour that could provide even more evidence for him that his belief is true. As a result, any adaptive response and further constructive consequences become unlikely, and he may focus even more on any mistakes he may make, which serve to reinforce the original belief of being “useless.” In therapy, this example could be identified as a self-fulfilling prophecy or “problem cycle,” and the efforts of the therapist and patient would be directed at working together to explore and shift this cycle.

People who are working with a cognitive therapist often practice the use of more flexible ways to think and respond, learning to ask themselves whether their thoughts are completely true, and whether those thoughts are helping them to meet their goals. Thoughts that do not meet this description may then be shifted to something more accurate or helpful, leading to more positive emotion, more desirable behaviour, and movement toward the person’s goals. Cognitive therapy takes a skill-building approach, where the therapist helps the person to learn and practice these skills independently, eventually “becoming his or her own therapist.”

Cognitive Model

The cognitive model was originally constructed following research studies conducted by Aaron Beck to explain the psychological processes in depression. It divides the mind beliefs in three levels:

  • Automatic thought.
  • Intermediate belief.
  • Core belief or basic belief.

In 2014, an update of the cognitive model was proposed, called the Generic Cognitive Model (GCM). The GCM is an update of Beck’s model that proposes that mental disorders can be differentiated by the nature of their dysfunctional beliefs. The GCM includes a conceptual framework and a clinical approach for understanding common cognitive processes of mental disorders while specifying the unique features of the specific disorders.

Consistent with the cognitive theory of psychopathology, CT is designed to be structured, directive, active, and time-limited, with the express purpose of identifying, reality-testing, and correcting distorted cognition and underlying dysfunctional beliefs.

Cognitive Restructuring (Methods)

Cognitive restructuring involves four steps:

  • Identification of problematic cognitions known as “automatic thoughts” (ATs) which are dysfunctional or negative views of the self, world, or future based upon already existing beliefs about oneself, the world, or the future.
  • Identification of the cognitive distortions in the ATs.
  • Rational disputation of ATs with the Socratic method.
  • Development of a rational rebuttal to the ATs.

There are six types of automatic thoughts:

  • Self-evaluated thoughts.
  • Thoughts about the evaluations of others.
  • Evaluative thoughts about the other person with whom they are interacting.
  • Thoughts about coping strategies and behavioural plans.
  • Thoughts of avoidance.
  • Any other thoughts that were not categorised.

Other major techniques include:

  • Activity monitoring and activity scheduling.
  • Behavioural experiments.
  • Catching, checking, and changing thoughts.
  • Collaborative empiricism:
    • Therapist and patient become investigators by examining the evidence to support or reject the patient’s cognitions.
    • Empirical evidence is used to determine whether particular cognitions serve any useful purpose.
  • Downward arrow technique.
  • Exposure and response prevention.
  • Cost benefit analysis.
  • Acting ‘as if’.
  • Guided discovery:
    • Therapist elucidates behavioural problems and faulty thinking by designing new experiences that lead to acquisition of new skills and perspectives.
    • Through both cognitive and behavioural methods, the patient discovers more adaptive ways of thinking and coping with environmental stressors by correcting cognitive processing.
  • Mastery and pleasure technique.
  • Problem solving.
  • Socratic questioning: involves the creation of a series of questions to
    • Clarify and define problems;
    • Assist in the identification of thoughts, images and assumptions;
    • Examine the meanings of events for the patient; and
    • Assess the consequences of maintaining maladaptive thoughts and behaviours.

Socratic Questioning

Socratic questions are the archetypal cognitive restructuring techniques. These kinds of questions are designed to challenge assumptions by:

  • Conceiving reasonable alternatives:
    • ‘What might be another explanation or viewpoint of the situation? Why else did it happen?’
  • Evaluating those consequences:
    • ‘What’s the effect of thinking or believing this?
    • What could be the effect of thinking differently and no longer holding onto this belief?’
  • Distancing:
    • ‘Imagine a specific friend/family member in the same situation or if they viewed the situation this way, what would I tell them?’
  • Examples of socratic questions include:
    • ‘Describe the way you formed your viewpoint originally.‘
    • ‘What initially convinced you that your current view is the best one available?‘
    • ‘Think of three pieces of evidence that contradict this view, or that support the opposite view. Think about the opposite of this viewpoint and reflect on it for a moment. What’s the strongest argument in favour of this opposite view?‘
    • ‘Write down any specific benefits you get from holding this belief, such as social or psychological benefits. For example, getting to be part of a community of like-minded people, feeling good about yourself or the world, feeling that your viewpoint is superior to others’, etc Are there any reasons that you might hold this view other than because it’s true?‘
    • ‘For instance, does holding this viewpoint provide some peace of mind that holding a different viewpoint would not?‘
    • ‘In order to refine your viewpoint so that it’s as accurate as possible, it’s important to challenge it directly on occasion and consider whether there are reasons that it might not be true. What do you think the best or strongest argument against this perspective is?‘
    • What would you have to experience or find out in order for you to change your ‘mind about this viewpoint?‘
    • Given your thoughts so far, do you think that there may be a truer, more accurate, or more nuanced version of your original view that you could state right ‘now?‘

False Assumptions

False assumptions are based on ‘cognitive distortions’, such as:

  • Always Being Right: “We are continually on trial to prove that our opinions and actions are correct. Being wrong is unthinkable and we will go to any length to demonstrate our rightness. For example, “I don’t care how badly arguing with me makes you feel, I’m going to win this argument no matter what because I’m right.” Being right often is more important than the feelings of others around a person who engages in this cognitive distortion, even loved ones.”
  • Heaven’s Reward Fallacy: “We expect our sacrifice and self-denial to pay off, as if someone is keeping score. We feel bitter when the reward doesn’t come.”

Awfulising and Must-ing

Rational emotive behaviour therapy (REBT) includes awfulising, when a person causes themselves disturbance by labelling an upcoming situation as ‘awful’, rather than envisaging how the situation may actually unfold, and Must-ing, when a person places a false demand on themselves that something ‘must’ happen (e.g. ‘I must get an A in this exam’.)

Types

Cognitive Therapy

based on the cognitive model, stating that thoughts, feelings and behaviour are mutually influenced by each other. Shifting cognition is seen as the main mechanism by which lasting emotional and behavioural changes take place. Treatment is very collaborative, tailored, skill-focused, and based on a case conceptualisation.

Rational Emotive Behaviour Therapy (REBT)

Based on the belief that most problems originate in erroneous or irrational thought. For instance, perfectionists and pessimists usually suffer from issues related to irrational thinking; for example, if a perfectionist encounters a small failure, he or she might perceive it as a much bigger failure. It is better to establish a reasonable standard emotionally, so the individual can live a balanced life. This form of cognitive therapy is an opportunity for the patient to learn of their current distortions and successfully eliminate them.

Cognitive Behavioural Therapy (CBT)

A system of approaches drawing from both the cognitive and behavioural systems of psychotherapy. CBT is an umbrella term for a group of therapies, where as CT is a discrete form of therapy.

Application

Depression

According to Beck’s theory of the aetiology of depression, depressed people acquire a negative schema of the world in childhood and adolescence; children and adolescents who experience depression acquire this negative schema earlier. Depressed people acquire such schemas through a loss of a parent, rejection by peers, bullying, criticism from teachers or parents, the depressive attitude of a parent and other negative events. When the person with such schemas encounters a situation that resembles the original conditions of the learned schema in some way, the negative schemas of the person are activated.

Beck’s negative triad holds that depressed people have negative thoughts about themselves, their experiences in the world, and the future. For instance, a depressed person might think, “I didn’t get the job because I’m terrible at interviews. Interviewers never like me, and no one will ever want to hire me.” In the same situation, a person who is not depressed might think, “The interviewer wasn’t paying much attention to me. Maybe she already had someone else in mind for the job. Next time I’ll have better luck, and I’ll get a job soon.” Beck also identified a number of other cognitive distortions, which can contribute to depression, including the following:

  • Arbitrary inference;
  • Selective abstraction;
  • Overgeneralisation;
  • Magnification; and
  • Minimisation.

In 2008 Beck proposed an integrative developmental model of depression that aims to incorporate research in genetics and neuroscience of depression. This model was updated in 2016 to incorporate multiple levels of analyses, new research, and key concepts (e.g. resilience) within the framework of an evolutionary perspective.

Other Applications

Cognitive therapy has been applied to a very wide range of behavioural health issues including:

  • Academic achievement.
  • Addiction.
  • Anxiety disorders.
  • Bipolar disorder.
  • Low self-esteem.
  • Phobia.
  • Schizophrenia.
  • Substance abuse.
  • Suicidal ideation.
  • Weight loss.

Criticisms

A criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e. neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). They may be single-blinded, the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in.

Deprescribing & Antidepressant Use in Older Adults

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Research Paper Title

Long term antidepressant use in a cohort of older people.

Background

Depression is the most common mental health problem in older adults and untreated is associated with significant burden of illness for patients. This study aimed to examine longitudinal patterns of antidepressant use in older adults and determine which factors were associated with changes in use.

Methods

Adults aged 50 and over, from the Irish Longitudinal Study on Ageing, who participated at any one of the four TILDA waves (n = 8,175) were included in the analysis. Repeated measures latent class analysis (RMLCA) is the model-based approach we used to identify underlying subgroups in a population.

Results

The researchers found antidepressant use ranged from 6% to 10%, over a 6-year period. RMLCA identified three distinct classes of anti-depressant use. Notably, 6% of older adults were categorised in a ‘long-term antidepressant use’ class, with consistent use across all four waves, and 6% were categorised in an ‘Intermittent/ Developing Use’ class. We found long-term antidepressant use to be a characteristic of older adults with chronic conditions at baseline of study and striking low uptake of psychological and psychiatric services.

Conclusions

These findings provide evidence of the complex presentations of depression with comorbidities in long-term antidepressant users. While prolonged use of antidepressants in an older cohort is often rationalised due to recurrent depression and comorbidities, this study suggests little deprescribing of antidepressants and a need for greater access and provision of psychological services tailored to later life seem necessary to improve management of this condition.

Reference

O’Neill, A., McFarland, J. & Kelly, D. (2021) Long term antidepressant use in a cohort of older people. International Journal of Geriatric Psychiatry. doi: 10.1002/gps.5518. Online ahead of print.

What is Mental Health Triage (Australia)?

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Introduction

Mental health triage is a clinical function conducted at point of entry to health services which aims to assess and categorise the urgency of mental health related problems.

Background

The mental health triage service may be located in the Emergency Department, Community Mental Health Services, Call Centre, or co-located with other specialist mental health services such as the Crisis Assessment and Treatment Team.

Emergency Services such as police and ambulance may also have a co-located mental health triage service.

There is considerable variation in the clinical settings in which mental health triage services may be operating, therefore service delivery models vary, however, the essential function is to determine the nature and severity of the mental health problem, determine which service response would best meet the needs of the patient, and how urgently the response is required.

A core function of mental health triage is to conduct risk assessment that aims to determine whether the patient is a risk of harming self or others as a result of their mental state, and to assess other risks related to mental illness. As with other triage models, the mental health triage clinician must assign a category of urgency to the case, which is recorded using verbal indicators of risk such as ‘extreme risk’ through to ‘low risk’, or by using numerical (urgency= time-to-treatment) categories 1 (immediate) to 5 (2 hours), as per the 5-point Australasian Triage Scale.

Mental Health Triage Training

In 2006 the Centre for Psychiatric Nursing Research and Practice introduced a 2 day mental health triage training programme designed and facilitated by Dr Natisha Sands.

The focus of the programme is on providing specific, targeted education to support triage duty and intake clinicians in conducting point of entry mental health assessment and service provision to Area Mental Health Services.

The aim of the programme is to increase the quality and consistency of mental health triage service delivery, by providing the clinician with sound theoretical and practical knowledge to guide clinical practice.

The expected outcomes of participation in the program are increased confidence and skill in triage clinical practice, improvement in the quality of service delivery, improvement in the quality of triage documentation, and professional development and support of clinical staff.

Brief Overview of the Programme

  • Telephone skills (phone manner, phone assessment, problem callers).
  • Risk assessment (assessment, diagnosis, priority, action).
  • Medico-legal issues.
  • Decision-making (the phases of triage, under pressure, influences, resource management, decision-making frameworks).
  • Negotiation skills (other agencies, team, clients, families).
  • Crisis management (identification, types of crises, problem solving, diffusion, resolution).
  • Secondary consultation and education (other services/agencies, clients, families).
  • Effective documentation (risk assessment, incidents, care planning, confidentiality, electronic documentation, exchange of information).
  • Engaging consumers (consumer centred service delivery).

The programme is open to mental health triage, duty, and intake clinicians of all disciplines, and is suitable for both novice and expert clinicians and is designed to assist clinicians engaged in both face-to-face and telephone only triage.

What is Psychological First Aid?

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Introduction

Psychological first aid (PFA) is a technique designed to reduce the occurrence of post-traumatic stress disorder. It was developed by the National Centre for Post Traumatic Stress Disorder (NC-PTSD), a section of the United States Department of Veterans Affairs, in 2006. It has been spread by the International Federation of Red Cross and Red Crescent Societies, Community Emergency Response Team (CERT), the American Psychological Association (APA) and many others. It was developed in a two-day intensive collaboration, involving more than 25 disaster mental health researchers, an online survey of the first cohort that used PFA and repeated reviews of the draft.

Refer to Crisis Intervention and Mental health First Aid.

Definition

According to the NC-PTSD, psychological first aid is an evidence-informed modular approach for assisting people in the immediate aftermath of disaster and terrorism to reduce initial distress and to foster short and long-term adaptive functioning. It was used by non-mental health experts, such as responders and volunteers. Other characteristics include non-intrusive pragmatic care and assessing needs. PFA does not necessarily involve discussion of the traumatic event. Just like physical first aid, psychological first aid focuses on providing effective initial support to individuals in distress.

Components

  • Protecting from further harm.
  • Opportunity to talk without pressure.
  • Active listening.
  • Compassion.
  • Addressing and acknowledging concerns.
  • Discussing coping strategies.
  • Social support.
  • Offer to return to talk.
  • Referral.

Steps

  • Contact and engagement.
  • Safety and comfort.
  • Stabilization.
  • Information gathering.
  • Practical assistance.
  • Connection with social supports.
  • Coping information.
  • Linkage with services.

Brief History

Before PFA, there was a procedure known as debriefing. It was intended to reduce the incidences of post traumatic stress disorder (PTSD) after a major disaster. PTSD is now widely known to be debilitating; sufferers experience avoidance, flashbacks, hyper-vigilance, and numbness. Debriefing procedures were made a requirement after a disaster, with a desire to prevent people from developing PTSD. The idea behind it was to promote emotional processing by encouraging recollection of the event. Debriefing has origins with the military, where sessions were intended to boost morale and reduce distress after a mission. Debriefing was done in a single session with seven stages: introduction, facts, thoughts and impressions, emotional reactions, normalisation, planning for future, and disengagement.

Debriefing was found to be at best, ineffective, and at worst, harmful. There are several theories as to why debriefing increased incidents of PTSD. First, those who were likely to develop PTSD were not helped by a single session. Second, being re-exposed too soon to the trauma could lead to retraumatisation. Exposure therapy in cognitive behavioural therapy (CBT) allows the person to adjust to the stimuli before slowly increasing severity. Debriefing did not allow for this. Also, normal distress was seen to be pathological after a debriefing and those who had been through a trauma thought they had a mental disorder because they were upset. Debriefing assumes that everyone reacts the same way to a trauma, and anyone who deviates from that path, is pathological. But there are many ways to cope with a trauma, especially so soon after it happens.

PFA seems to address many of the issues in debriefing. It is not compulsory and can be done in multiple sessions and links those who need more help to services. It deals with practical issues which are often more pressing and create stress. It also improves self efficacy by letting people cope their own way. PFA has attempted to be culturally sensitive, but whether it is or not has not been shown. However, a drawback is the lack of empirical evidence. While it is based on research, it is not proven by research. Like the debriefing method, it has become widely popular without testing.

Today, PFA has been widely used not just for crisis intervention for natural disasters, but also personal crises such as when individuals face traumatic losses of loved ones or pets, or when organisations go through critical incidents such as the suicide or death of a colleague.

Overview of Mental Health First Aid

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Introduction

Mental health first aid is a training programme that teaches members of the public how to help a person developing a mental health problem (including a substance use problem), experiencing a worsening of an existing mental health problem or in a mental health crisis. Like traditional first aid, mental health first aid does not teach people to treat or diagnose mental health or substance use conditions. Instead, the training teaches people how to offer initial support until appropriate professional help is received or until the crisis resolves.

While first aid for physical health crises is a familiar notion in developed countries, conventional first aid training has not generally incorporated mental health problems.

Refer to Crisis Intervention and Psychological First Aid.

Rationale

Mental health problems are common in the community, so members of the public are likely to have close contact with people affected. However, many people are not well informed about how to recognise mental health problems, how to provide support and what are the best treatments and services available. Furthermore, many people developing mental disorders do not get professional help or delay getting professional help Someone in their social network who is informed about the options available for professional help can assist the person to get appropriate help. In mental health crises, such as a person feeling suicidal, deliberately harming themselves, having a panic attack or being acutely psychotic, someone with appropriate mental health first aid skills can reduce the risk of the person coming to harm.

There is also stigma and discrimination against people with mental health problems, which may be reduced by improving public understanding of their experiences.

Brief History

The Mental Health First Aid Programme was developed in Australia by Betty Kitchener and Anthony Jorm in 2000. Since 2003, this Mental Health First Aid Programme has spread to a number of other countries (Bermuda, Canada, Denmark, England, Finland, France, Germany, Hong Kong, India, Ireland, Japan, Malaysia, Malta, Netherlands, New Zealand, Northern Ireland, Saudi Arabia, Scotland, Sweden, Switzerland, United States, United Arab Emirates, Wales). By 2019, over 3 million people had been trained in mental health first aid worldwide.

Research on Mental Health First Aid Training

A number of studies have been carried out showing the people who are trained in mental health first aid showed improved knowledge, confidence, attitudes and helping behaviour. A meta-analysis of data from 15 evaluation studies concluded that mental health first aid training “increases participants’ knowledge regarding mental health, decreases their negative attitudes, and increases supportive behaviours toward individuals with mental health problems”.

There has been research to develop international guidelines on the best strategies for mental health first aid. Mental health first aid training has been included in the US Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programmes and Practices.

By Country

Australia

In Australia, mental health first aid training is run by the not-for-profit charity Mental Health First Aid International (trading as Mental Health First Aid Australia). A range of training courses are offered:

  • Standard Mental Health First Aid is a 12-hour face-to-face course for adults to learn to assist other adults.
    • Culturally adapted versions of this course are available for Chinese and Vietnamese Australians.
    • eLearning and blended versions of the Standard course have been tailored for a range of professional groups, including pharmacists, the legal profession, financial counsellors, medical students and nursing students.
  • Youth Mental Health First Aid is a 14-hour face-to-face course for adults to learn to assist adolescents.
  • Aboriginal and Torres Strait Islander Mental Health First Aid is a 14-hour face-to-face culturally adapted course for adults to learn to assist Aboriginal and Torres Strait Islander adults.
    • It is run by Aboriginal or Torres Strait Islander instructors.
  • Teen Mental Health First Aid is a 3.5-hour classroom-based course that teaches high school students in years 10-12 how to provide mental health first aid to their friends.
  • Older Person Mental Health First Aid is a 12-hour face-to-face course for adults to learn to assist people aged 65 and over.

By 2015, Mental Health First Aid training had been received by over 350,000 people, which is more than 2% of the Australian adult population.

Mental health first aid training programmes in Australia have won a number of awards for excellence including:

  • Gold Achievement Award 2007 – winner of the Mental Health Promotion Mental Illness Prevention Programme or Project category at the MHS Conference.
  • Suicide Prevention Australia – 2005 Life Award.
  • Victorian Public Health Programmes Award for Innovation, 2006.
  • Enterprise and Resourcefulness Award – NSW Aboriginal Health Awards 2010.
  • Silver Achievement Award for Aboriginal and Torres Strait Islander Programme – Mental Health Promotion or Mental Illness Prevention Programme or Project category at the MHS Conference 2010.
  • Silver Achievement Award for Youth Mental Health First Aid Programme – TheMHS, Mental Health Promotion or Mental Illness Prevention Programme Category, 2014.
  • TheMHS Medal (the top award of the Mental Health Service Awards of Australia and New Zealand which “honours a unique and inspiring contribution to Mental Health by an individual or organisation”), 2017.

England

Mental health first aid (MHFA) came to England in 2007 and was developed and launched under the National Institute for Mental Health in England, part of the Department of Health, as part of a national approach to improving public mental health. Mental Health First Aid England was launched as a community interest company in 2009.

MHFA England offer a range of courses:

  • Standard MHFA, a two-day course which qualifies a participant to become a Mental Health First Aider
  • Youth MHFA, a two-day course which qualifies a participant to become a Youth Mental Health First Aider.
    • This course is designed for those who are working, living or interacting with young people.
    • It was first launched in England in 2010 and revised and re-launched in October 2013.
  • Youth MHFA Schools & Colleges, a one-day course which is based on Youth MHFA and designed to fit into school training timetables.
  • Armed Forces MHFA, a two-day course which qualifies participants to become an Armed Forces Mental Health First Aider.
    • This course was designed for the whole Armed Forces community, including veterans, serving personnel and their families.
    • It was launched 2013.
  • MHFA Lite, a three-hour introductory awareness course launched which is based on the Standard MHFA course.
    • MHFA Lite was launched in 2011.
    • There is also a Lite version of the Youth MHFA course.
  • MHFA Instructor Training, a seven-day course accredited by the Royal Society for Public Health to qualify as a Mental Health First Aid instructor who can deliver one or all of the two-day courses (Standard, Youth and Armed Forces).

Since 2007, more than 114,000 Mental Health First Aiders have been trained in England and more than 1,600 people have trained as Mental Health First Aid instructors. The Department of Health encouraged all employers in England to provide mental health first aid training as one of three steps in its 2012 “No Health Without Mental Health: Implementation Framework”. In 2016 Mental Health First Aid was recommended for all workplaces by the charity Business in the Community.

Scotland, Wales, and Northern Ireland have broadly similar courses to the above.

You can find further information on the various UK courses here.

Ireland

In May 2014 Saint John of God Hospital signed a Memorandum of Understanding with MHFA Australia to adapt the course for Ireland and in October 2014 Betty Kitchener came to Saint John of God Hospital to advise on the rollout of the MHFA Ireland Programme.

United States

In 2008, the National Council for Behavioural Health, in partnership with the Missouri Department of Mental Health, brought mental health first aid to the United States. Since 2008, more than 1.5 million people have been trained on the Mental Health First Aid USA course by an instructor base of more than 15,000. There are people trained in mental health first aid in all 50 states, Puerto Rico and Guam. The course is offered to a variety of audiences, including hospital staff, employers and business leaders, faith communities and law enforcement.

In 2012, youth mental health first aid was introduced in the United States to prepare trainees to help youth ages 12-18 that may be developing or experiencing a mental health challenge. Specialised versions of Mental Health First Aid USA including the Veterans, Public Safety, Higher Education, Rural and Older Adults modules and a Spanish version of the Youth and Adult curriculum are also available.

Mental Health First Aid USA was included in President Barack Obama’s plan to reduce gun violence and increase access to mental health services. In 2014, Congress appropriated $15 million to SAMHSA to train teachers and school personnel in youth mental health first aid. In 2015, an additional $15 million was appropriated to support other community organizations serving youth. The Mental Health First Aid Act of 2015 (S. 711/H.R. 1877) had broad bi-partisan support and would authorise $20 million annually for training the American public. Fifteen states have made Mental Health First Aid a priority by appropriating state funds, including Texas which allocated $5 million.

Canada

Mental health first aid debuted in Canada in 2007, and has operated under the leadership of the Mental Health Commission of Canada since early 2010.

MHFA Canada offers a range of courses, which, upon completion, certify a participant in mental health first aid:

  • MHFA Basic, a two-day 12 hour course.
  • MHFA for Adults who Interact with Youth, a two-day 14 hour course.
  • MHFA Seniors, a two-day 14 hour course.
  • MHFA Veteran Community, a two-day 13 hour course.
  • MHFA Northern Peoples, a three-day 18 hour course.
  • MHFA First Nations, a three-day 20 hour course.
  • MHFA Inuit, a three-day 24 hour course.
  • MHFA Police, an eight-hour course including 15-30 minutes online.
  • MHFA Instructor Training, a course which allows the participant to become a Mental Health First Aid instructor.

Different instructor courses are required to become a MHFA Basic, Youth, Seniors, Veteran Community, First Nations or Northern Peoples instructor. The duration of these courses vary from five to six days. First Nations & Northern People versions require two instructors/facilitators to deliver the course.

Since 2007, more than 400,000 Canadians have been trained in Mental Health First Aid, and more than 1,200 people have been trained as instructors.

United Arab Emirates

Mental health first aid debuted in the UAE in December 2017. MHFA UAE operates under the leadership of the Lighthouse Centre for Wellbeing, an out-patient mental health clinic in Dubai composed of more than 25 licensed psychologists. The Lighthouse is the only accredited provider of MHFA in the UAE.

MHFA UAE offers 3 courses:

  • Adult to Adult MHFA, a 12-hour training which qualifies a participant to become a Mental Health First Aider.
    • This course is designed for those who are working, living or interacting with other adults.
  • Adult to Adolescent MHFA, a 14-hour course which qualifies a participant to become a Youth Mental Health First Aider.
    • This course is designed for those who are working, living or interacting with young people.
  • Teen to Teen MHFA, a 4-hour course which qualifies teens to become Teen Mental Health First Aiders.

What is Crisis Intervention?

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Introduction

Crisis intervention is a time-limited intervention with a specific psychotherapeutic approach to immediately stabilise those in crisis.

Refer to Mental Health First Aid and Psychological First Aid.

Implementation

A crisis can have physical or psychological effects. Usually significant and more widespread, the latter lacks the former’s obvious signs, complicating diagnosis. Three factors define crisis: negative events, feelings of hopelessness, and unpredictable events. People who experience a crisis perceive it as a negative event that generate physical emotion, pain, or both. They also feel helpless, powerless, trapped, and a loss of control over their lives. Crisis events tend to occur suddenly and without warning, leaving little time to respond and resulting in trauma.

At a global level, when a mass trauma from an event like as a terrorist attack occurs, counsellors are trained to provide resources, coping skills, and support to clients to assist them through their crisis. Intervention often begins with an assessment. In countries such as the Czech Republic, crisis intervention is an individual therapy, usually lasting four to six weeks, and includes assistance with housing, food, and legal matters. Long waiting times for resident psychotherapists and in Germany, explicit exclusions of couples therapy and other therapies complicate implementation. In the United States, licensed professional counsellors (LPCs) provide mental health care to those in need. Licensed professional counsellors focus on psychoeducational techniques to prevent a crisis, consultation to individuals, and research effective therapeutic treatment to deal with stressful environments.

School-based

The primary goal of school-based crisis intervention is to help restore the crisis-exposed student’s basic problem-solving abilities and in doing so, to return the student to their pre-crisis levels of functioning. Crisis intervention services are indirect. People often find school psychologists working behind the scenes, ensuring that students, staff, and parents are well-positioned to realize their natural potential to overcome the crisis. School psychologists are trained professionals who meet continuing education requirements after receiving their degree. They help maintain a safe and supportive learning environment for students by working with other staff. such as school resource officers, law enforcement officers trained as informal counsellors and mentors.

At a school-based level, when a trauma occurs, like a student death, school psychologists are trained to prevent and respond to crisis through the PREPaRE Model of Crisis Response, developed by NASP. PREPaRE provides educational professionals training in roles based on their participation in school safety and crisis teams. PREPaRE is one of the first comprehensive nationally available training curriculums developed by school-based professionals with firsthand experience and formal training.

Misuse

When using crisis intervention methods for the disabled individual, every effort should first be made to first find other, preventative methods, such as giving adequate physical, occupational and speech therapy, and communication aides including sign language and Augmentative Communication systems, behaviour and other plans, to first help that individual to be able to express their needs and function better. Too often, crisis intervention methods including restraining holds are used without first giving the disabled more and better therapies or educational assistance. Often school districts, for example, may use crisis prevention holds and “interventions” against disabled children without first giving services and supports: at least 75% of cases of restraint and seclusion reported to the US Department of Education in the 2011-2012 school year involved disabled children. Also, school districts hide their disabled child’s restraint or seclusion from the parents, denying the child and their family the opportunity to recover.

The US Congress has proposed legislation, such as the “Keeping All Students Safe Act”, to curtail school district use of restraint and seclusion. Even with bipartisan support, the bill has repeatedly died in committee.

SAFER-R

The SAFER-R Model, with Roberts 7 Stage Crisis Intervention Model, is model of intervention much used by law enforcement. The model approaches crisis intervention as an instrument to help the client to achieve their baseline level of functioning from the state of crisis. This intervention model for responding to individuals in crisis consists of 5+1 stages. They are:

  • Stabilise.
  • Acknowledge.
  • Facilitate understanding.
  • Encourage adaptive coping.
  • Restore functioning or,
  • Refer.

Other models include Lerner and Shelton’s 10 step acute stress & trauma management protocol.

Critical Incident Debriefing

Critical incident debriefing is a widespread approach to counselling those in a state of crisis. This technique is done in a group setting 24-72 hours after the event occurred, and is typically a one-time meeting that lasts 3-4 hours, but can be done over numerous sessions if needed. Debriefing is a process by which facilitators describe various symptoms related PTSD and other anxiety disorders that individuals are likely to experience due to exposure to a trauma. As a group they process negative emotions surrounding the traumatic event. Each member is encouraged to continue participation in treatment so that symptoms do not worsen.

Commentators have criticised critical incident debriefing for its effectiveness on reducing harm in crisis situations. Some studies show that those exposed to debriefing are actually more likely to show symptoms of PTSD at a 13-month follow-up than those who were not exposed. Most recipients of debriefing reported that they found the intervention helpful. Based on symptoms found in those who received no treatment at all, some critics state that reported improvement is considered a misattribution, and that the progress would naturally occur without any treatment.

Interoceptive Impairment & Non-Suicidal Self-Injury

Published on by Andrew MarshallLeave a comment

Research Paper Title

A multi-measure examination of interoception in people with recent nonsuicidal self-injury.

Background

Self-injurious behaviors (SIB) are highly dangerous, yet prediction remains weak. Novel SIB correlates must be identified, such as impaired interoception. This study examined whether two forms of interoceptive processing (accuracy and sensibility) for multiple sensations (general, cardiac, and pain) differed between people with and without recent nonsuicidal self-injury (NSSI).

Methods

Participants were adults with recent (n = 48) NSSI and with no history of SIBs (n = 55). Interoceptive sensibility was assessed with self-reports. Interoceptive accuracy for cardiac sensations was assessed using the heartbeat tracking task. Interoceptive accuracy for pain was assessed with a novel metric that mirrored the heartbeat tracking test.

Results

Participants with recent NSSI reported significantly lower interoceptive sensibility for general sensations relative to people without SIBs. Groups did not differ on interoceptive sensibility for cardiac sensations or pain. Groups also did not differ on interoceptive accuracy for cardiac sensations. The NSSI group exhibited significantly lower interoceptive accuracy for pain compared with the No SIB group.

Conclusions

Interoceptive impairment in people with NSSI may vary by interoceptive domain and sensation type. Diminished interoceptive accuracy for sensations relevant to the pathophysiology of self-injury may be a novel SIB correlate.

Reference

Forrest, L.N. & Smith, A.R. (2021) A multi-measure examination of interoception in people with recent nonsuicidal self-injury. Suicide & Life-Threatening Behaviour. doi: 10.1111/sltb.12732. Online ahead of print.