Working with cognitive behavioural therapy – Introducing CBT to a client

For a therapy that has great empirical support and can be used by any and all members of the interdisciplinary team, you can’t really go far from cognitive behavioural therapy. Waaaay back in the olden days when I was originally trained as an occupational therapist, CBT was the province of psychologists only – and possibly there are a few out there who would like it to stay that way! But in pain management it’s vital to integrate CBT throughout the whole team so that consistent responses are made. So this week I’ll be covering some practical ways to use CBT within ‘other’ therapies – especially physiotherapy and occupational therapy.

I’m not going to review the many studies demonstrating support for CBT, this is a practical series, so the first step is probably working out how to introduce CBT to a client. Several key principles inform my practice – the first is that we are collaborating. That means I am no expert on what will work best for this client (and I don’t have a complete understanding of what is going on for that person either!). This helps me from ever thinking that I’m superior to him or her – we are in this together!
The next principle is that we are developing an understanding over time – the therapy process is really a journey of discovery. Some of the things I suggest may not be appropriate – or it may not be the right time to introduce them.
And further – eventually this person is going to do this for themselves. I don’t want to be a long-term therapist!
And finally, CBT in the management of chronic pain is not a personality overhaul – we’re not trying to make this person ‘different’, we’re hoping they will understand a bit more of what is happening, that they can learn new ways of viewing their situation, and that they can develop a range of ways to manage in their situation so they can choose.

A great book that has some lovely worksheets and puts CBT into a framework that I find helpful is Renee Taylor’s ‘Cognitive behavioral therapy from chronic illness and disability’ (2006) Springer:New York. ISBN-10: 0-387-25309-2
I’ll be dipping in and out of it throughout the week – as well as referring to some articles and other books I have in my library. (You don’t want to know how many books I have!!)

How do OT’s and Physio’s use CBT? It depends a little on the activities you are undertaking – so here’s my quick take on it.

• There are opportunities to provide information (on request) about the effect of thinking on emotion and coping. Times such as when a person starts learning about factors that influence their pain – stress, fatigue, anger.
• When introducing a form of activity pacing or working to quota often provides an opportunity to ask ‘what went through your mind when we started to talk about this?’
• When the person starts doing an activity and demonstrates a shift in emotion/affect or similar – again, asking ‘what went through your mind when I suggested we do this?’
• When the person has been invited to continue with an activity in between sessions and doesn’t manage it.
• When providing information about a model of chronic pain.
• When emotions are evident.
• When helping the person generalise a coping skill such as self regulation breathing or setting goals

Do you get the idea that there isn’t really any time when you can’t use CBT?!

More about this tomorrow – in the meantime, consider this: When you start to think about thinking, what happens?