Why CBT? How do patients feel about it?


There are many different therapies out there – why is CBT (or one of the newer variants) the Chosen One?
I gave a few reasons yesterday –
* 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
Here are a few more…

  • help people become more likely to stick to ‘other’ interventions
  • provide opportunities for people to reflect on the choices they make, especially the choices about healthy behaviour
  • help people recognise their own power and role within their own health care team, and their responsibilities
  • help people develop a sense of control over their own health
  • reduce the effects of stressors
  • reduce the misleading effects of anxiety and concern (e.g. reduce the search for a ‘cure’ or ‘another diagnostic investigation’

In chronic pain management there is plenty of research-based evidence that programmes building on these principles help people recover to a more normal life, and especially, return to normal life roles. CBT-based programme are not, however, very specifically prescribed – researchers still don’t know how much or what constitutes ‘necessary’ and ‘sufficient’ elements in a programme.

One of the main problems with initiating CBT-oriented therapy is that people with a health problem, especially pain, really DON’T want the slightest hint that their pain could be ‘imaginary’, ‘psychological’, ‘malingering’, ‘in my head’, nor about them being ‘unable to cope’. Introducing the idea of CBT initially can be quite challenging if it’s carried out as if it’s separate from any other aspect of the person’s health care. This is another strong reason for it to be integrated and conducted by any and all members of the team.

Introducing CBT

A lot of CBT books suggest ‘socialising’ the person to CBT – I’m not entirely comfortable with this idea myself! It sounds a lot like the demand characteristics of a therapeutic setting are being used to ‘make’ the person ‘conform’ to how I as a therapist want sessions to be run. My preference is to use the menu approach, as I think I’ve mentioned before. menu I’ve attached one for you to download if you want.

Once the person’s identified what they see as their concerns, I can start talking about some of the ways other people have worked through or solved their problems. This can often mean the person comes up with their own solutions – and my job is to then, with their permission, help them put that solution into a framework that can help them understand how or why it might work.

An example? One of the people I’m seeing currently has difficulty sleeping. She’s fine getting off to sleep, but just can’t stay asleep. She has worked out that she finds it really difficult to get comfortable again once she’s woken up, and then her mind becomes very busy.

Her thought for a good way to manage this was to work out how she could get comfortable more quickly – and she knew from the menu I’d used that learning how to relax might be helpful. We’ve started developing her skills in relaxation – but I’ve added in the following cognitive model to help her understand why it might work.

  1. She’s quite a busy person and doesn’t relax readily. She goes off to sleep very quickly because she’s very fatigued, but waits to go to bed when she’s really exhausted. As a result, she doesn’t allow herself to experience that relaxed dosiness that most of us get.
  2. When she wakes in the middle of the night, she’s recovered from some of her fatigue, so because she doesn’t know how to fall asleep again, she starts to become anxious – especially when she thinks of the coming day, and how much she needs to have good sleep!
  3. As she starts to worry, her body starts to respond to the increased anxiety, and she becomes more aroused physiologically – this increases her general anxiety and she becomes more aware of (and hypervigilant to) her back pain. She also has less to distract her from her worries and her pain because it’s quiet and she is alone.

I also took the time to discuss the stress response – and she was able to identify a number of factors that are increasing her anxiety at present, and how this is experienced in her body. She arrived at the conclusion that prior to her back pain, she was able to ‘work off’ some of her ‘stress’ by keeping very busy and by carrying out fitness activities also. Without her usual outlets for ‘stress’ she reflected to me that she has been finding it harder to wind down.

At the same time as identifying the stress, pain, arousal, sleep problems – this woman has also identified that she’s not sure why she keeps so busy all the time. She’s pondering this and it may be something she discusses with the psychologist on our team. And next time we meet, she intends to see how the relaxation process we went through has worked – and she’s also been given some other information on sleep hygiene to review.

Without even attempting to ‘socialise’ her to CBT, a common structure for CBT sessions is developing – starting each session with an ‘agenda’ or menu, reviewing her past learning (‘homework’ -ugh! missions if you please – you do have a choice about whether you want to accept them or not!), identifying the elements that have worked well, those that haven’t, and reviewing new pieces of information as we go.

For my next post, I’ll describe a situation that hasn’t moved so smoothly so you can see that it doesn’t always work out exactly as I want! But in this case, I think I’ve been able to start where she is at, give her the responsibility to identify what is important to her, and the solutions she has identified (which demonstrates my belief that she has the resources to cope and increases her confidence in herself), help her fit the solutions she has come up with into a framework that makes sense and opens up an opportunity for more factors to be added in for future exploration.

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