Before we start on cognitive behavioural therapy, we need to know what we’re on about – for me in pain management, CBT assumes:
- that people are capable of change,
- can accept self responsibility for their actions,
- that what we think and believe about a situation can affect our emotions and responses, and
- that we can implement a whole range of strategies that can make a difference to life
We may not make a huge difference in terms of the actual medical condition – but as we know, the diagnosis is not the same as the health condition! And it’s health status on which CBT really has an impact in chronic health conditions.
Although it’s similar to the way CBT is applied in mental health situations in terms of looking at thoughts, beliefs, rules, attitudes, emotions and behaviours – it’s much more about the helpfulness of these things than the ‘accuracy’ of them. In mental health, often the thoughts are inaccurate – ‘other people think I’m bad’ or ‘I must keep my hands clean or else it will be a disaster’ or ‘I’m totally inadequate and nothing I do is good enough’.
In chronic health it may be more like ‘I can’t trust medicine to fix me’, or ‘If I keep bending, my pain will get worse’, or ‘I should be able to cope with this’. Some of these thoughts are accurate, some are inaccurate – and some may be accurate but are unhelpful.
So, as therapists, we are concerned with helping people become aware of usually hidden thoughts and beliefs. We then help the person identify whether these beliefs help them achieve their life goals (or valued/important activities), then alter them or work to establish ‘exceptions’ that may help them rather than hinder them.
At the same time, we’re working with the person to achieve personally relevant goals – things like achieving refreshing sleep, being able to return to paid employment, communicating well with their families, having invigorating leisure time. These activities require planning, monitoring achievement, altering behaviours and recruiting support in order to achieve them. And yes, these are all legitimate areas for input by an interdisciplinary health care team.
The process for me is to start with really good assessment across the domains that are relevant for the health condition in question. In pain management, I’m interested in attitudes, behaviours, compensation, diagnostic beliefs, emotions, family and friend interactions, and work – amongst a lot of other things. From this I want to add in – what does this person want to be able to do? What does the person referring him or her want them to do (why did they refer this person?).
Then I want to work with the person to help them achieve their goals – this means developing some ‘working’ explanations for how they’ve arrived at having the problems they are experiencing. Because I use a biopsychosocial model, I try to put together the information from all three domains – biophysical, psychological and social. This process can take quite a while, and doesn’t need to be complete – and for me, has to be shared with the person.
Most of the time the person is quite clear about how well this explanation ‘fits’ for them – and it’s not so unfamiliar for many of us who work as therapists. We usually give an explanation for the treatment we are giving – the main difference is that we work collaboratively with the person and recognise that we actually don’t know whether what we are suggesting is the ‘correct’ answer. This is because in most chronic health management situations, it’s not a simple 1+1 – it’s more a case of multiple factors interacting in a bunch of ways!
Applying CBT isn’t confined to cognitive theories, or behavioural theories, it’s much more about values – and readiness to act, based on importance and confidence – as well as allowing people the opportunity to choose.
How does this differ from normal therapy? Not a lot really – it’s simply expanding our treatment model to include factors that we know influence whether a person will or won’t change their behaviour. And this should apply to any health professional – physiotherapists need to know that people will carry on with their exercises, occupational therapists need to know what stops someone incorporating working to quota, social workers need to know how to help people approach anxiety-provoking activities, and nurses need to help people complete daily recordings!
But – more tomorrow!