CBT and ACT - an integrated strategy

CBT and ACT - an integrated strategy

Whilst we’ve seen some progress towards process based CBT and a more integrated approach to the different forms of cognitive behavioural therapy, there is still a tendency towards CBT “separatism”. In particular, some proponents of the ACT model argue that Acceptance and Commitment Therapy is fundamentally different or superior to other forms of CBT. Drawing on philosophical differences between functional contextualism and the rational - empirical school, ACT purists argue that conceptual differences prevent an integrated approach to CBT.

In this brief article I wanted to offer an alternative perspective that supports the process based approach brilliantly outlined in Steve Hayes’ recent book “Process Based CBT”.

How ACT and Mainstream CBT Work Together

ACT focuses on process and perspective in thinking, including the rules of language in thought construction. so in other words – how we think, rather than what we think.

CBT focuses on content, process, and perspective. So in other words what we think and how we think.

For many psychological problems, it’s often important to integrate content, process and perspective when altering the clients relationship with unhelpful or problematic cognitions.

When working with panic disorder for example,  it’s helpful to challenge irrational thoughts about cardiac death, teach the client to notice and normalise their reactions to catastrophic thoughts and reframe the thoughts as an oversensitive internal alarm system.

Thought challenging and defusion are different ends of the same cognitive continuum. I think it’s unhelpful to present them as opposites, when we can help our clients to see them as complimentary alternatives to changing their relationship with thoughts.

In my personal experience as a practising clinician, clients often (but not always) need to challenge the content of their thoughts en route to defusion. Sometimes we need to know what we are letting go off before we let go of the cognitive and behaviour struggle.

In the UK,ACT is professionally recognised by the BABCP as a third wave cognitive behavioural therapy.

It’s important to learn the ACT disciplines of defusion and acceptance, whilst recognising that this does not exclude appropriate thought challenging.

As you can tell, I am a CBT integrationist, not an ACT separatist!

I know that there are philosophical differences between CT and ACT, however we should acknowledge these differences rather than using them to mutually exclude the other approach.

There are enough anti-CBT publicists primarily from the psychoanalytic tradition and its derivatives, without perpetuating the problem by entering our own into internecine battles.

ACT, CT, CBT, DBT, IBT, MBCT and REBT all share the same therapeutic tradition and approach. in the UK each of these approaches is acknowledged as a first, second or third wave form of cognitive behavioural therapy. If we support the emerging process based CBT strategy, they are all methodologies with an established CBT tradition that spans back to the 1950s.

To find out how we integrate the different forms of evidence based CBT into our clinical work, visit https://www.Eiretherapy.ie/

Quality Assurance for CBT

Quality Assurance - Why It's Important to Check Therapist Credentials Before Starting Cognitive Behavioural Therapy

Over the last two years there has been a significant increase in counsellors and therapists offering Cognitive Behavioural Therapy (CBT). 

Whilst it's encouraging to see so many therapists from other therapeutic areas finally engaging in CBT, this has also contributed to a level of confusion about what being a Cognitive Behavioural Psychotherapist actually involves.

This confusion has been propagated in part by the growth of online therapy and psychology directories. 

These directories have managed to attain a virtual monopoly on top ranked searches for therapy in the UK. 

A couple of well-known psychology directories offer therapist verification; however, they also allow counsellors and therapists from other disciplines to advertise CBT services without checking their specific CBT training or credentials. 

To test this out, we tried ten searches for CBT in different areas of the UK and found that less than 10% of the results listed in a popular psychology directory were verifiable Cognitive Behavioural Psychotherapists. 

The title Cognitive Behavioural Psychotherapist is not a protected professional term, which means that anybody can use the title without the recognised professional training, clinical practice and supervision. 

We have also seen social media advertisements offering training courses to become a “Cognitive Behavioural “Therapist” with as few as sixteen hours online training.

So how do we protect the public and ensure that people make informed choices when it comes to booking and paying for private CBT?

The immediate answer is to check CBT credentials by visiting the UK CBT register at www.cbtregisteruk.com

This is the only quality assurance check to confirm whether your Cognitive Behavioural Psychotherapist is professionally accredited by the British Association of Behavioural and Cognitive Psychotherapy (BABCP). 

The BABCP is the UK professional body for the practice and maintenance of professional standards in CBT. The UK CBT register is used by all of the major insurance providers and many other professional bodies to check the status of CBT psychotherapists before permitting insurance panel registration. At Think CBT, we are verified providers for all of the major insurance providers in the UK and you can see what we offer by visiting www.thinkcbt.com you can also check the UK independent CBT registry at https://cbtpages.com/

So what are the minimum training standards and thresholds for professional practice as a CBT psychotherapist in the UK?

To apply for provisional accreditation with the BABCP, the applicant must be able to demonstrate the following criteria:

• A minimum of 12 months in a psychological core profession such as HCPC registered clinical psychologist, psychiatrists, social worker or professionally accredited counsellor. There is an extensive portfolio exercise known as the KSA assessment for individuals without a core profession to demonstrate the equivalent.
• Completion of a BABCP approved level 2 post-graduate training programme. Not all master’s level CBT training programmes in the UK fully meet the rigorous standards applied by the BABCP. 
• A minimum of 450 hours specialist post-graduate level CBT training. This also involves written assignments, logs, case studies and research assignments totalling approximately 25,000 words 
• A minimum of 40 hours professional CBT supervision  delivered by a recognised CBT supervisor.
• Presentation of eight clinical cases for full supervision.
• Three written case studies of up to 4,000 words per case study to demonstrate competency in clinical practice.
• A minimum of 200 hours of supervised clinical work as a trainee CBT practitioner.
• Two written references covering clinical supervision and wider professional practice.

Once these criteria have been met, the therapist may apply for provisional accreditation by the BABCP. Provisional accreditation lasts for 12-18 months, during which time the provisionally accredited CBT psychotherapist must demonstrate adherence to the BABCP codes of practice and professional standards. 

This includes a minimum of 90 minutes clinical supervision each month by a recognised CBT supervisor and engagement in a further five CBT training / learning activities.

Only at the end of this period is the psychotherapist permitted to apply for full accreditation as a CBT Psychotherapist.

The reason why the BABCP accreditation standards are so rigorous, is to help ensure the highest standards of professional practice and to protect the public.

What if my therapist isn’t on the UK CBT register?

Whilst there are some therapists who can meet these minimum training and practice standards without electing to join the BABCP, it’s important to personally check your therapists credentials if they are not on the UK CBT register. 

It’s also worth noting that the similarly sounding BACP which represents the wider counselling profession does not accredit or professionally uphold CBT standards. BACP accreditation does not mean that your therapist is a CBT specialist.

If your counsellor or therapist is offering specialist CBT service and is not professionally accredited by the British Association of Behavioural and Cognitive Psychotherapy (BABCP), our advice is to use the following simple check-list:

• Do they have a minimum of 450 hours specialist post-graduate level training in CBT?
• Have they completed 40 hours of CBT specific clinical supervision?
• Have they completed a minimum of 200 hours of supervised practice as a CBT Practitioner?
• Have they completed and past a level 2 BABCP accredited post-graduate training programme?

Some therapists have completed post-graduate level CBT training and will offer credentials that provide an equivalent to the above criteria, however it’s often difficult to compare and quality assure without independent professional advice.

This is what we offer at Think CBT

If you work with a Think CBT Psychotherapist, you can be assured that you are working with an accredited CBT expert. We only offer services that we are professionally qualified and accredited to deliver and we only work with clients when we are confident that we can help. WE quality assure our team members so that our clients don’t have to worry. 

If you want advice or guidance on any of the above points, contact Think CBT via info@thinkcbt.com or by visiting our website at www.thinkcbt.com

Disclaimer: the information in this article reflects the opinions of Think CBT and does not represent the position of any other professional / membership body.

Rip-Off Therapy - Too Many Hand-offs in the System

There are a growing number of private therapy providers in the UK who are making significant commercial gains out of the employee assistance, legal and insurance sectors by charging hefty fees for the provision of CBT, counselling or psychological services.

In our experience, these charges can range from double to four times the amount paid to the therapists providing these services.

These charges are typically made by the middle-layer EAP and psychological service providers who operate the administrative gap between the client and the Therapist.

We’ve also heard some real horror stories about poor data management, unqualified staff undertaking triage assessments and breach of ethical boundaries.

These excessive charges and inadequate practices are not in the interests of the client nor the therapist providing a service.

There are too many layers and commercial handoffs in the process and the emerging model exaggerates the true cost of providing quality therapy.

We recently received an Insurance referral made via an outsourced EAP, to a well-known CBT Business who finally subcontracted the service to us. The client disclosed that our therapy charges were only 35% of the total charges made. Sadly, this example is fairly typical.

The UK private therapy environment is increasingly shifting to replicate a multi-layer sub-contracted commercial model, where the needs of the patient and the Therapist are subordinated by the scope for commercial profit.

Smaller commercially responsible psychological services exist; however, they often lack the business skills or scalability to compete with the larger emerging psychological service providers.

At Think CBT we operate on a commercially ethical basis, ensuring that therapists are paid the full rate for the service they provide. We promote collaboration and mutuality without exploiting the client, the system or the therapist.

We provide a network of supervised and accredited Therapists. Our Therapists work as a practice community, sharing resources and working to common service standards. To support this, we deliver group and individual supervision on a monthly basis. This is delivered on a cost-neutral basis to reduce the financial burden of organising private supervision.

We do apply a nominal one-off admin fee to cover the basic overheads required to process clients from enquiry to appointment, however we don’t rip off our colleagues or set ourselves up to compete with each other.

If you are a BABCP accredited therapist working in London, Kent, Surrey, Sussex or Essex, join the Think CBT associate network for access to private referrals and free monthly supervision.

This post is not about self-promotion, it’s about advocating fairness and mutuality in the provision of private therapy.

To find out more, email info@thinkcbt.com or visit our website at www.thinkcbt.com.

The Psychology of Obsessive Compulsive Disorder – A Simple Model of OCD

Over recent years Obsessive Compulsive Disorder (OCD) has received popular exposure through TV and social media. This has however contributed to the idea that OCD is a quirky inconvenience or humorous eccentricity. The fact is that this couldn’t be further from the truth. OCD is a highly debilitating anxiety condition which can lead to profound suffering and reduced quality of life.

In this article I will briefly outline what OCD is, how it is maintained and how to best treat the problem. To find out more about OCD you can visit our OCD page at https://thinkcbt.com/ocd-cbt-treatment.

What is OCD?

OCD is a highly distressing anxiety related condition affecting around 1.2% of the general population. In the UK this equates to around 750,000 people. OCD is now clustered together with other Obsessive Compulsive related disorders including Body Dysmorphic Disorder, Trichotillomania, Hoarding Disorder and Excoriation Disorder.

How Does OCD Work?

OCD can be divided into three reciprocal processes. Firstly, intrusive negative thoughts or disturbing images, sometimes referred to as Egodystonic intrusions.  Secondly, repetitive negative obsessions including ruminations, worry and self-doubting and thirdly, repetitive behaviours or neutralising rituals referred to as compulsions.

The negative intrusive thoughts are often perceived as personally repugnant and are highly distressing. The obsessions cause rumination, worry and self-doubt leading to feelings of anxiety, shame, disgust and depressed mood. The neutralising behaviours or rituals are accepted as irrational but highly habit forming and incredibly difficult to break.

When the individual is triggered by a negative intrusive thought, image or memory, this initiates the obsessional thinking process. The sufferer experiences intense worry or self-doubt leading to high levels of emotional distress. The Compulsion is then used to undo or neutralise the obsessional anxiety.

Over time, this process can become engrained and automatic. Long-term OCD sufferers are often aware of the compulsive element without being consciously aware of the intrusive thought or obsession. The compulsion gradually becomes a reflexive process for controlling or avoiding anxiety. The way to uncover the originating intrusive thoughts and obsessions behind the compulsive behaviour, is to explore the implications of not performing the behaviour or ritual. This can have important implications for the application of ERP, outlined later in this article.

The Role of Operant Learning, Conditioned Responses and Inhibitory Learning

There are three important psychological processes at play between the obsessions and compulsions in the maintenance of OCD and this has important implications for effective treatment.

The first process is based on Operant Learning and is referred to as negative reinforcement. The compulsion or neutralising habit provides immediate relief from the obsessional anxiety. This  relief is “negatively reinforced” as it helps take the distress or discomfort away. In behavioural terms, if the relief is greater than the loss experienced by performing the compulsion, the compulsive behaviour will continue. This explains why OCD sufferers logically understand the futility of the compulsion, but still struggle to stop the compulsive behaviour.

The second important psychological process is based on Classical Conditioning and is known as a Conditioned Response. This means that the three OCD components of the intrusion, the obsession and the compulsive behaviour are associated in an automatic chain reaction. Again, OCD suffers fully appreciate the irrationality of their obsessions and behaviours, however the conditioned response makes it extremely difficult to break this engrained and automatic association.

The combined effects of negative reinforcement and the conditioned response make the OCD process highly addictive and incredibly difficult to break. The sufferer is often torn between logically understanding the OCD, yet emotionally feeling compelled to perform the compulsions to dial down their uncertainty and anxiety.

In addition to The combined effects of negative reinforcement and the conditioned association between the compulsion and the trigger, performing compulsions also prevents the disconfirmation of the feared situation. This prevents a process known as “Inhibitory learning“, whereby the individual learns that they are able to cope effectively with the feared situation. Inhibitory learning is a key principle behind modern approaches to ERP, which is detailed in the following section.

Effective Treatments

The most effective researched treatment for OCD is Cognitive Behavioural Therapy. A number of specific CBT processes have been found to be highly effective in breaking the addictive OCD cycle.

These processes include cognitive reappraisal of obsessional worry and self-doubt, Exposure Response prevention, something called cognitive defusion, a new approach known as Inference Based Therapy and guided behavioural work on personal values. Whilst each of these approaches require specialist support from a trained Cognitive Behavioural Psychotherapist, some key points are briefly outlined below:

Cognitive Reappraisal – this involves psychoeducation and skills training to teach the client how to catch, check and change obsessional worry and self-doubts. The client is taught how to identify, test and intercept negative patterns of thinking that super-charge the intrusion and lead to the need to perform the compulsion.

Whilst cognitive reappraisal has an important part to play in understanding and challenging irrational obsessions, it can inadvertently reinforce the OCD struggle if not supported correctly by a trained CBT specialist. Struggling with obsessional thoughts, even when the struggle is positive, can still ratchet up the obsessional process and contribute to increased attention on the worry or self-doubt.

Exposure Response Prevention – ERP is the longest established and most well researched approach to the treatment of OCD. It primarily involves teaching the client how to minimise, suspend, interrupt or prevent the compulsion. Whilst traditional ERP uses Classical Conditioning principles to habituate the anxiety response, it involves a process known as Inhibitory Learning. Exposure to the obsessional worry, rumination or doubt, helps the client to relearn and assumptions about there ability to cope with the implications of not performing compulsions.

It is important that traditional ERP is applied on an integrated basis involving graded exposure and behavioural experiments. If ERP is applied as a blunt instrument, it can leave the client feeling overwhelmed and contribute to high drop out rates.

Another angle on ERP is Exposure Relevant to Purpose. This engages the client in altering rather than stopping behaviour and is based on a special form of CBT known as Acceptance and Commitment Therapy. This is briefly outlined in the section covering values below.

Cognitive Defusion – This is one of the six core processes in Acceptance and Commitment Therapy also known as ACT. ACT itself has been found to be highly effective in the treatment of OCD as it teaches clients to disengage from and normalise their obsessional worries an self-doubts. Cognitive Defusion helps the client to see thoughts as thoughts, rather than facts or evidence.

Cognitive Defusion is normally supported by mindfulness practice, work on acceptance and values based action.

Values – Traditional OCD treatments focus on a preventative or remedial approach to OCD, helping the client to move away from distressing thoughts and unhelpful behaviours. This “away from” approach can inadvertently set the client up for failure and emphasise the struggle that characterises OCD itself.

Values based action, is drawn from the ACT model and encourages the client to “move towards” their personal life commitments. It encourages empowerment and asks the client to exercise flexibility and choice when confronted by their distressing thoughts and worries.

This involves identifying compelling reasons to change behaviour that provide greater levels of positive reinforcement than the relief normally associated with performing the compulsion.

Inference Based Therapy – This is a relatively new form of Cognitive Therapy with relevance to OCD related problems. IBT works on the premise that OCD is maintained by patterns of personal self-doubt. Clients are taught how to alter the impact of self-doubts by identifying the difference between inverse inferences and observable facts. IBT helps clients to distinguish between normal doubts and obsessional doubts, so that compulsions become less relevant and unnecessary.

How to Organise Effective OCD Therapy

OCD is a complex problem with many different manifestations. Modern treatment for OCD involves a mix of advanced Cognitive and Behavioural approaches which are most effectively treated with the support of a properly trained and BABCP accredited Cognitive Behavioural Psychotherapist. Always check that your psychologist, Psychotherapist or Counsellor is properly accredited with the British Association of Behavioural and Cognitive Psychotherapy. This will help to ensure that you are working with a competent CBT specialist in the first instance.

The next step is to check that your CBT specialist has experience working with OCD and that they have additional specialist training including ERP, ACT or IBT. This will help to ensure that you are exposed to a combination of effective evidence based techniques to support the specific aspects of the OCD presentation.

For more information about the different forms of OCD you can visit our OCD page at https://thinkcbt.com/ocd-cbt-treatment. You can also contact us by emailing info@thinkcbt.com

William Phillips is a qualified and BABCP accredited Cognitive Behavioural Psychotherapist with specialist interests in OCD-related problems. To find out more about William, you can visit his profile page at https://thinkcbt.com/team/william-phillips.

You can also access free CBT resources and online assessments by visiting our website at https://thinkcbt.com.