12/10/2017 1 Challenges for CBT - What are the Evidence - Based Choices? Professor Chris Williams University of Glasgow and Director Five Areas Ltd Declaration of conflict of interest Current challenges • Tension between access to care and capacity • Extension of targets into groups relatively underserved • Challenges to evidence base- is CBT (low intensity and high intensity) as good as claimed? • What to offer - effectively and ethically How to translate research findings into practice? Key issue: • Increasingly complex • Individual papers not enough (researcher allegiance/ samples chosen/what is done and wider applicability) • Systematic reviews giving conflicting results • Opinion pieces can be as influential as treatment guidelines • Treatment guidelines – criticisms of the process/not always implemented • Critiques of data interpretation • Lobbying by special interest groups • Answers are becoming less clear/more uncertain What matters in services? • Engagement and access – how do we do this? • Assessment: – who are we working with? • What are we offering that engages and helps? • One sized fits all – or personalised? • How can we improve outcomes?
Transcript
12/10/2017
1
Challenges for CBT- What are the Evidence - Based
Choices?
Professor Chris Williams
University of Glasgow
and Director Five Areas Ltd
Declaration of conflict of interest
Current challenges
• Tension between access to care and capacity
• Extension of targets into groups relativelyunderserved
• Challenges to evidence base- is CBT (lowintensity and high intensity) as good asclaimed?
• What to offer - effectively and ethically
How to translate research findingsinto practice?
Key issue:• Increasingly complex• Individual papers not enough (researcher allegiance/
samples chosen/what is done and wider applicability)• Systematic reviews giving conflicting results
• Opinion pieces can be as influential as treatment guidelines• Treatment guidelines – criticisms of the process/not always
implemented• Critiques of data interpretation• Lobbying by special interest groups• Answers are becoming less clear/more uncertain
What matters in services?
• Engagement and access – how do we do this?
• Assessment: – who are we working with?
• What are we offering that engages and helps?
• One sized fits all – or personalised?
• How can we improve outcomes?
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Let’s go back to basicsEvidence based therapies:
3 critical components affect outcome
1. Clear structure of working
2. Focus on problems relevant to theperson
3. Built on a relationship with thepractitioner
What leads to good outcomes?
Relationship
What leads to good outcomes?
Relationship
Structure of working
An example: How does CBT work?
Has anyone said…. What you said last time reallymade a difference…• I.e. patterns of effective questions• Plus teaches skills to make changesKey point: CBT has a structure and solutions thatcan make sense of symptoms
A form of psychotherapy?• All about teaching/learning• Can be taught in different ways
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Situations, relationships and Practical Problems
AlteredThinking
Altered Feelings Altered PhysicalSymptoms
AlteredBehaviour
Example: “Classic” CBT structure: FiveAreas Assessment (Williams) Can the structure of CBT be offered in
different ways?
Different formats via:
• Groups/classes
• Books
• Online
• Shortened forms such as brief behavioural activation
• Maintain the STRUCTURE of CBT and FIDELITY
• Raises issues about the benefits of added training….
Key principles: choice of LI CBTapproaches?
• Evidence based
• Accessible
• Avoid Information overload
• Stories/Questions
• Clearly presented
• Usable…. 25% of people struggle toread at reading age 11
Book TitleReading age
(average: adult healthcare)
Coping with Depression - Blackburn (1987) 14.4
The Feeling Good Handbook - Burns (1980) 13.4
Feeling Good – The New Mood Therapy -Burns (1999)
15.4
Manage Your Mind - Butler & Hope (1995) 14
Overcoming Depression - Gilbert (1997) 14
Mind over Mood - Greenberger & Padesky(1995
15
Overcoming depression and low mood: afive areas approach (2nd Edition) - Williams(2006)
12.6
The right language: Martinez et al (2008)
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Resources that engage- Who? Overview: Evidence based working
Non Specific factors
100%
50-60%
Evidence based working
Evidence based modele.g. CBT
100%
Non Specific factors
Evidence based working
Much focus here intraining courses andguidelines
Very Specific factors
Relatively less focushere
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Are all talking therapies prettymuch the same?
• Claim is non-specific factors are the mostimportant aspect – relationship is key - YES
Also:
• It doesn’t matter what form/model of therapyis then offered – they are all the same –
TESTABLE
Some key questions
• Is Cognitive Behavioral Therapy the Gold Standard forPsychotherapy? The Need for Plurality in Treatment andResearch
JAMA: Leichsenrig and Steinert Sept 2017Published online September 21, 2017.doi:10.1001/jama.2017.13737
• Cuijpers P, Cristea IA, Karyotaki E, Reijnders M,Huibers MJ. How effective are cognitive behaviortherapies for major depression and anxiety disorders? ameta-analytic update of the evidence. World Psychiatry.2016;15(3):245-258
What they found
• Cochrane risk of bias tool: only 17% (24 of 144) of RCTswere high quality
• CBT cf waiting list condition >80% studies (anxiety) 44%(depression)
• High-quality studies: CBT was found to be less efficaciousthan in low-quality studies
• High-quality studies, CBT achieved large effect sizes onlyin comparison with waiting list conditions.
• Cf with TAU effect sizes were only small to moderate(0.30-0.45).
• In panic disorder, CBT was not more effective thantreatment as usual but only to waiting list.
Taking a step back: two key goals
• Why do I feel as I do?
• How to feel better/make changes?
• Model used needs to make sense to the person
• Provide an explanation/meaning
• Fit their own narrative or provide a credible narrative
• Fit their expectations of what’s needed to get better
• French et al – Behavioural and Cognitive therapy(Cobalt follow-up)
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Patient/person preference is alsopart of the mix
2 year follow up of our original Lancet Cobaltpaper
• People still using CBT approaches were peoplefor whom it made sense
• Wanted to take an active part in self-therapy
• Those not still using it preferred to tell theirstory
Some further challenges to what isoffered
• cCBT can make you worse (OCTET trial)
• cCBT can be very disappointing even fordepression and anxiety
Farrand and Woodford:
• Shorter/minimal LI support for guided CBTgives the best results (Farrand and Woodford)
• Impact seems greatest for phone supports
Assessment key decisions:Low intensity or High Intensity?
• Is there an evidence-based LI model?
• Is it appropriate for this person?
• Can they use it?
• Do they want to use it?
• Not based on severity alone
Evidence based working
Structure of working
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Accessing help The Inverse Care Law
1
Care
Access and distance Travel or Parking issues
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Even harder when you have a LTCe.g. pain, stroke, angina, COPD
Anxiety and depression make it evenharder
Let’s look around the room Jargon cuts people out
CognitionsDysfunctionalNegative reinforcement• Can baffle people, perplex, baffle or make
them feel stupid
• It’s a lot to ask…..
Key concepts:• Information overload• Prior learning
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Assessment with a purposeOur joint assessment Evidence based working
Maximisingrelationshiop/
support
What’s our therapeutic role?
• Professional?
• Practitioner?
• Teacher?
• Supporter?
• Coach?
• Motivator?
• Encourager?
Working your Mojo(using the relationship)
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How much and what type ofsupport?
The Importance of Support?
Support matters – but how much?
LI 213 patients a year cf HI 72 per yearLI typically 5 sessions cf HI 12 sessions
Not at all clear higher depression scores alonemeans LI not appropriate (Farrand/Woodford)Cuijpers et al (2013) - equal results for guided CBTand HI interventionsWhat does this mean in practice?
Focus more on process
Are we asking the right questionsin allocating to therapy?
NICE deals with studies – grouped data
What about at an individual level?
Let’s go away on holiday together….
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Do a learning assessmentHow do you like to learn?
How do you want to work?
• Perhaps the issue is also very much aboutengagement and maintaining motivation tochange
It’s hard to change:Remember January .....
Plan, Do, Review approach
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Evidence based working
What has evidence?
What engages?
What are we offering?What would NICE say?
• cCBT
• Guided Self-Help
• Pure Self Help
• Behavioural Activation
• Exercise
• Psychoeducation Groups
Improving outcomes
Balance of structure and relationshipRCT study designs/evidence – and consider pragmaticimplementation
How to retain the strengths/benefits of structuredapproaches:TrainingManualised modelsSupervisionRelationship
Personalisation: EHIC and ETIC
• Etic approaches assume universal presentations-depression is depression and depressiontreatments are what is needed
• Emic: local cultures matter
• Cultures differ across the UK and across localcommunities
• Cultural adaptations are needed
• Language matters – psychological mindedness…
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Summary: Solutions to thedilemmas faced
• How do you like to learn/work?• How can I help you?
• Key issue: how to translate research findings into practice• Engagement and access – how do we do this?• Assessment: – who are we working with?• What are we offering?• Improving outcomes• “Cultural adaptation” balancing structure and relationship• Evidence and localisation that is evidence-led and measured/tested• Based on Evidence based content – but locally adapted to work• No one size fits all – personalised learning assessment
