Cognitive behavioural therapy: Brain power

Cognitive Behavioural Therapy (CBT) is becoming the first choice in the government’s strategy for helping people with mental health problems – mainly depression – to stay in or return to work. Its advocates include Professor Richard Layard of the Centre for Economic Performance’s Mental Health Group, its detractors encompass the late Professor Phil Richardson, former professor of clinical psychology at Essex University.

Layard’s vision of the future entails psychological centres offering a CBT approach that GPs and OH practitioners could refer to. But Richardson had grave concerns about the economic efficiency and long-term effect of such a solution. His research with chronically depressed patients at the world-renowned Tavistock Clinic in London indicates that many of these people have not responded well to CBT in the past and reveals fears that CBT is too readily being hailed as a convenient cure-all.

Debate opened

CBT has at least opened up the debate and many OH practitioners are gaining qualifications in CBT. So what are the views of practitioners who have used CBT to help people return to work? Does their experience suggest that the technique should be applied to all mental illness problems afflicting the workplace?

Helen Riches has been an OH adviser for the National Institute of Biological Standards and Control, in Hertfordshire, for five years. Riches had counselling skills but found herself ‘out of her depth’ with certain situations she encountered at work and wanted to offer a better service.

In 2007, she took the Certificate in CBT for OH Professionals course given by Alan Dovey and Sharon Davey at the Institute of Occupational Medicine at Birmingham University. It involved attending the course for one day a month for five months, plus working on a case study.

Riches believes that her ability as an OHN has been enhanced by the course. She also believes it has strengthened her instinctive approach to helping employees who have difficulties in returning to work or have problems dealing with difficult people, that are manifested in ‘avoidance behaviour’.

An example of an exercise from the course that Riches has used in practice is the ‘chair-envelope presentation’.

Envelopes are placed under seats at a managers’ conference and delegates are told that in one there are instructions to give a five-minute presentation on a specific subject. No one knows if they have the envelope under their chair.

Hidden triggers

In fact, none of the envelopes contain this instruction. What is important is the reaction the possibility triggers in the recipient’s mind. According to CBT theory, it will engender thoughts that affect your behaviour depending upon your past experience of giving presentations. Bad memories can have an adverse effect on performance, whereas those who have enjoyed giving presentations in the past may relish the opportunity now. CBT teaches that recognising negative thoughts and replacing them with positive ones will affect behaviour.

Riches remembers an employee who took time off work to avoid giving presentations because the person had difficulty presenting complex data. “Once they recognised this and recognised their limitations, and undertook further training to improve their skills, their confidence was boosted and their performance improved,” she says.

Riches is confident that CBT has made her a more effective OH practitioner by helping her understand and respond to managers’ concerns.

“Basically, if you can understand their thinking you can understand their behaviour and so can hopefully find a solution to their workplace problem,” she says.

And what about psychologists and counsellors on the front line?

Annie Hargrave is a practising psychoanalytical psychotherapist with the charity Interhealth Worldwide. She agrees with Richardson that “CBT can be incredibly effective for the right person at the right time, but it is not appropriate for every situation. At Interhealth we take the evidence base seriously and use CBT and IPT (interpersonal therapy) skills, as recommended in the NICE guidelines. But assessment for each individual is a big priority”.

Integrative therapy

John Steley, a psychologist who is also based at Interhealth, describes himself as an ‘integrative’ therapist because he tends to select the treatment he believes is most appropriate for the individual situation and client.

“You can get incredibly good results with CBT,” he says.

“But you need more than one type of therapy in your tool kit. For example, when dealing with people who have been systematically abused in childhood or have complex bereavement reactions.”

While CBT has proved to be effective treatment for many employees suffering from mild to moderate depression, the experience of practitioners suggests that the government should reconsider its plans so that funding is given to other types of therapy rather than just to CBT.

Each individual should be assessed and then be given access to the most appropriate therapy, rather than, as practitioners suggest may sometimes happen, the most convenient one.

Jane Downey is OH manager at Interhealth

Nic Paton, Saving Souls, Occupational Health, Vol 59:7 August 2007

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