Is CBT the missing link?

Cognitive behavioural therapy (CBT) has amassed a wealth of evidence demonstrating its effectiveness in treating a wide range of psychological disorders since US psychology professor Aaron Beck first introduced its conceptual framework in 1979.

The National Institute for Health and Clinical Excellence (NICE, 2004) has recommended CBT as a primary intervention for depression, anxiety disorders and post-traumatic stress disorder. A British Occupational Health Research Foundation (BOHRF) study by Linda Seymour and Bob Grove in 2005 similarly recommended it as the treatment of choice for helping people with common mental health problems to remain in the workplace and make an effective adjustment to health and productivity.

The financial cost of work lost as a result of mental health problems is universally acknowledged by researchers, and fully appreciated by employers. Estimates reported by the Health and Safety Executive (HSE) in 2005, for example, indicate that self-reported work-related stress, depression and anxiety accounts for 12.8 million lost working days per year in the UK. It is increasingly evident that initiatives to reduce absenteeism are moving to the forefront of the health and safety agenda, particularly with the recognition that longer-term absences tend to hinder an employee’s successful return to work.

A study in 2005 by employers’ body Business in the Community estimated that absence cost employers some £28.6bn in 2004, and statistics suggest that individuals with primary mental health problems constituted a significant group within this profile. An HSE report in 2005 indicated that, of the 2.2 million people who suffered from work-related ill health in 2003-04, up to 75% were cases of stress or musculoskeletal disorders. In November 2003, it was estimated that 44% of all individuals who received incapacity benefit in the UK were suffering from mental health or behavioural disorders, according to statistics from the Department for Work and Pensions.

Cognitive behavioural therapy

CBT could be a highly cost-effective way to reduce sickness absence or even prevent the loss of highly valued staff from the workforce as a result of mental health problems.

The underpinning theory of CBT is that people who become depressed or anxious do so because they engage in maladaptive or faulty thought processing (cognitions) and reasoning, which are self-defeating, and affect mood, behaviour and physiology in characteristic ways. As these negative thinking patterns intensify, the associated mood, behaviours and physical symptoms are further entrenched, creating a cyclical emotional ‘trap’ and a sense of reduced control over daily functioning.

CBT utilises structured therapeutic techniques directed at achieving particular goals and strategies to help people alter maladaptive patterns of thinking and behaviour that serve to start or sustain mental health problems. It focuses on negotiating clear and practical strategies for challenging and changing negative thinking patterns and self-defeating types of behaviour.

Clients are set goals which achieve changes in structured and measurable ways, often achieved through homework tasks negotiated between the therapist and the client, such as the use of diaries to record moods and thoughts, or activity schedules, which aim to promote autonomy, responsibility and control.

CBT emphasises collaboration and active participation from both the therapist and the client. It is goal-oriented and problem-focused, and tends to emphasise the present, rather than the distant past. It has a strong educational component with structured sessions, and the course of therapy aims to be short-term, or at least have finite limits in duration. Evidence shows CBT has a high level of effectiveness, particularly in the treatment of depression and anxiety disorders.

It might be tempting for one to argue for a substantial investment in CBT practitioners who can be ‘parachuted in’ to address all ills. The NHS has acknowledged a shortage of CBT practitioners, and occupational health services have traditionally relied on small numbers of counsellors to support staff with mental health problems.

A more effective and co-ordinated approach to addressing the need for CBT skills in occupational health settings could be to invest in training occupational health professionals in basic CBT strategies and consultation skills.

This does not imply all occupational health professionals should become CBT therapists. However, there could be benefits for OH professionals who develop CBT skills, as the way it encourages autonomy and goal-orientated thinking and behaviour can also be helpful for practitioners’ own decision-making skills and confidence.

One way of addressing limited resources is to develop a co-ordinated, tiered structure of differing levels of CBT knowledge to ensure a more effective allocation of available resources to staff with differing needs. This approach has been applied with some success in a number of NHS services, as shown in the paper Tiered Approach: Matching Mental Health Services of Need, published in the Journal of Mental Health in 2000.

Three-tiered approach

The tiered approach involves three levels of resource: primary, secondary and tertiary.

At a primary level, OH professionals may benefit from a working knowledge of the basic principles of CBT theory and practice that may help them to make decisions about which employees require further monitoring, referral on to more specialist practitioners, or access to self-help material, including computerised CBT programmes.

At a secondary level, a small number of OH professionals (with time allocated for learning) could be trained in more advanced levels of CBT skills to work alongside CBT practitioners and counsellors. They would provide short-term therapy services for people with common mental health problems who are able to remain at work or within close proximity to the workplace.

At a tertiary level, there would be an identified resource of a small number of ‘experts’ available to OH services to co-ordinate training and supervision, and to provide direct clinical services to staff with more complex difficulties, or who have been absent as a result of mental health problems.

If BOHRF recommendations are to be realised, the matter of resourcing needs to be addressed in an innovative way. Many employers may be discouraged to invest in the new development of such services because of the potential high costs in the short-term, even if the savings in the medium-term are potentially significant.

However, they may be more inclined to agree with the argument that investment in the further training of current occupational health professionals in such skills, leading to a systematic evolutionary development of more CBT-based services, makes sense in the current health economy.

Dr Les Smith is head of clinical governance at FirstAssist. Dr Tony Parker is a psychologist and director of training at Psicon, and L J Conradie is a psychologist and managing director at Psicon. Please direct any queries or comments about this article to the authors at enquiries@psicon.co.uk

References



  • Confederation of British Industry (1999) Focus on Absence: 1999, Absence and Labour Turnover Survey, London, CBI
  • Department of Health (1996) The ABC of Mental Health in the Workforce, Health of the Nation, London, HMSO
  • Health and Safety Executive (2005) Survey of Self-Reported Work-Related Illness, London, HSE
  • National Institute of Health and Clinical Excellence (2004) NICE Guidelines
  • Paxton, R, Shrubb, S, Griffiths, H, Cameron, L, and Maunder, L (2000) Tiered Approach: Matching Mental Health Services of Need, Journal of Mental Health, 9:2, 137-144
  • Seymour L and Grove B (2005) Workplace Interventions for People with Common Mental Health Problems,
    London, BOHRF

Courses for OH practitioners

A study by two specialists in cognitive behavioural therapy into the effects of signing off individuals with anxiety and depression from work, showed that sickness absence often serves to reinforce depression and anxiety. Following a series of discussions with OH practitioners, Alan Dovey, honorary clinical lecturer in cognitive behavioural therapy (CBT) and Sharon Wilday, consultant cognitive behavioural psychotherapist, both at the University of Birmingham, discovered that certain elements of CBT could be utilised by OH advisers.

They developed a two- to five-day evidence-based training programme for OH practitioners which uses a variety of psychosocial interventions, including CBT. The authors aim to help organisations develop their own in-house CBT and psychosocial training to address sickness absence due to anxiety and depression, and have also submitted their course for accreditation to become a module on the university’s occupational health diploma course.

For more information: Dovey A and Wilday S, (2005) All in the mind? Occupational Health, Vol 57, No: 9, 25-28. Contact Alan Dovey at alan@adovey.fsnet.co.uk



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