Helena Brady and Anne Harriss highlight some of the theory on which cognitive behavioural therapy (CBT) is based. They explore a case study of a client presenting with anxiety, which affected their attendance at work.
Occupational health practitioners frequently see clients in response to management referrals resulting from sickness absence associated with depression and anxiety, but there are few practitioners that are specifically qualified as mental health specialists.
Many are now, however, gaining qualifications in CBT as an adjunct to OH support, to assist people reporting symptoms of anxiety that impact on their work attendance or performance.
The National Institute for Health and Care Excellence recognises the value of CBT by featuring an example of its use within OH in an NHS trust on its website (Airdale NHS Trust, 2009).
Case study: the client
Sarah, an administrative worker, was referred by her manager for advice and support regarding her repeated sickness absences associated with a diagnosis of depression and a family bereavement. Although Sarah’s symptoms of depressive illness improved following medication, she developed anxiety and become phobic about her return to work (RTW), precipitating a further extended period of sickness absence.
CBT was used as an intervention to support her in returning to work. CBT is designed to be short term, problem focused and goal directed and is defined by Blenkiron (1999) as “structured, problem orientated and set in the here and now”. It is an effective short-term treatment for emotional disorders. Important features of CBT interventions are that they are focused, brief, and problem orientated.
While suggesting a picture of a basic and simple approach to common mental health problems, CBT approaches are far from simplistic: efficacy depends on client engagement and a good rapport between client and therapist.
The theoretical concepts of CBT underpinning the treatment of anxiety relate to fight or flight responses, coupled with learning theories of classical and operant conditioning.
Blenkiron (1999) suggests that CBT is the treatment of choice for anxiety. Wilday and Dovey (2005) suggest that anxiety is an emotional response activated by fear-based cognition. The “fight-or-flight” response copes with physical danger by fighting or fleeing. In effect it is the same response activated by the sight of a predator being mobilised by threats of psychological traumas, such as rejection (Beck et al, 2005).
Through interaction with others via a variety of learning processes, we develop our beliefs of ourselves, other people, the world and the future (Dovey and Wilday, 2012). The origins of the behavioural component of CBT are rooted in concepts of learning theories including classical and operant conditioning (McGinn and Sanderson, 2001).
The basic tenet of classical conditioning is that the pairing of a neutral stimulus with an unconditioned stimulus leads to the production of certain responses, even when these previously neutral (now conditioned) stimuli were presented on their own (McGinn and Sanderson, 2001).
The OH assessment for Sarah identified behaviours, cognitions and emotions with related biological symptoms. Emotionally, she felt overwhelmed and anxious that she might be unable to cope on returning to work. Her reluctance came from concerns regarding facing colleagues with dominant personalities within her team. Behaviourally, she was disengaged from work and had lost social contact.
Cognitively, she expressed the belief that she was unable to cope, using the analogy of having “hit a brick wall”. She reported having difficulty falling asleep, waking throughout the night, and experiencing tiredness upon waking.
Significant factors for her included difficult relationships both at work and at home; such as the unexpected death of a family member 18 months earlier had negatively affected her family.
Dovey and Wilday (2012) highlight that core beliefs are often rooted in childhood events. They may, or may not, have been true when first believed. Such early life experience culminates in the development of core beliefs; in Sarah’s case, being bullied in childhood elicited the belief that others cannot be trusted, her ensuing rule for living therefore became avoidance of situations that put her at risk.
In the cognitive development model, which begins in early life, a core belief is activated by a trigger, culminating in the maintenance cycle of underlying negative core beliefs.
The bullying that Sarah experienced in childhood involved name-calling and playground social exclusion. Her early life experiences, in line with the principles of learning by association, resulted in experiences of playground name-calling eliciting an anxiety response. Name-calling was paired with being left to play alone; being left alone became a stimulus for anxiety.
Sarah’s early life experiences and response to the anxiety of bullying are most likely to have led to unpleasant feelings. Beck et al (2005) recognise that if an unconditioned response is evaluated to be unpleasant, then anything paired with the stimulus is also perceived as negative and unpleasant.
Sarah believed that favouritism by management towards the dominant personalities of her colleagues resulted in cliques from which she was excluded, which elicited responses of anxiety. Emotionally, she felt overwhelmed, anxious and unable to cope with facing her team members. Behaviourally, she avoided people and disengaged from work and social contact.
The processes of operant conditioning are evident in Sarah’s avoidance behaviour. Hardy and Heyes (1999) suggest that behavioural changes result from reinforcement after the desired effect is elicited, highlighting that if a response has pleasant consequences, it is more likely than other responses to occur again under the same circumstances.
Work avoidance reduced Sarah’s anxiety as she did not have to face her colleagues. The positive reinforcement associated with this avoidance continued that behaviour, thus maintaining her anxiety. Butler and McManus (2000) suggest that reinforcement can be positive: providing something pleasant by removing something unpleasant. Sarah’s avoidance behaviour was thus also reinforcement. The avoidant behaviour removed the work situation that was the source of the anxiety.
Sarah exhibited behaviours including only engaging superficially with people, stating that “this keeps people at a distance”. In essence, this became her self-created “rule for living”. The anxiety trigger factor was social exclusion associated with workplace “cliques” resulting from her perception of favouritism within the team.
This isolation may have reinforced her negative belief that people must be kept at arm’s length, congruent with the negative core belief that isolation brings about consonance for her. Sarah expressed that her social isolation was enforced because of favouritism that she felt was being thrust upon her. This workplace social exclusion made her feel more exposed and this triggered anxiety. Her feelings of isolation were also exacerbated by this perceived favouritism and thus an anxiety response and enforcing maintenance cycle was elicited. CBT was identified as a way to help her deal with her situation.
The interventions: behavioural and cognitive
Moorey (1996) recommends graded exposures to feared situations as a behavioural technique, aiming for successful habituation of the feared stimulus. A “downward arrow” technique and thought diary were cognitive approaches used to identify and test dysfunctional thoughts and beliefs.
Sarah’s initial belief was that she had hit a brick wall and was therefore unable to cope. Her negative thoughts became progressively worse to the extent that her initial thought of not coping culminated in worries about losing her job and being unable to support her family. In essence, her thoughts were not balanced; the initial thought did not equate to the latter thought. Through the understanding of the framework of the downward spiral technique, Sarah was able to recognise her particular negative thinking style: catastrophising.
Drilling down in this way helped Sarah and the OH practitioner become aware of these beliefs and thus they could be integrated into her therapeutic interventions. From that point, a series of achievable goals can be identified to make more significant and helpful behavioural changes
Downward arrow events
1. I have hit a brick wall and I cannot cope.
2. I might not be able to cope if I go back to work.
3. If I cannot cope, I might become ill again.
4. If I get ill again, I will have to go off sick.
5. Next time it will be worse and I will not ever be able to get back to work.
6. I will lose my job.
7. I will not be able to pay my mortgage.
8. I will lose my home.
9. I will not be able to support my family.
There are two components to CBT as an approach: the first is a cognitive approach considering thoughts and mental processes; and the second considers behaviour. Opinion has been divided among the cognitive and behaviour therapists as to whether or not behavioural changes come before cognitive changes or vice versa (Moorey 1996). Using “downward arrow events”, enabled Sarah to further understand why the feeling of not being able to cope had had such an impact.
As Sarah reflected on why she had felt so distressed, it became apparent that she was catastrophising her circumstances. She worried that negative thoughts could have an impact on her continued employment, resulting in a loss of income. She began to comprehend that isolated feelings of being unable to cope did not compute to losing her job and being unable to support her family. She realised that her thoughts were negative and unbalanced. She realised that her avoidant behaviour from work was fuelling the negative thought of being unable to cope; so she was avoiding work and thus avoiding the opportunity to prove to herself that she might be able to manage.
She set a goal to return to work by a specific date. Subsequently, a schedule was set up assisting her to achieve her goal that was specific, measurable, achievable, realistic and time orientated (SMART) (Wilday and Dovey 2005).
The first step was for Sarah to complete an anxiety baseline worksheet. She identified that her reluctance to even enter her work premises was the single most significant hurdle preventing her from returning to work.
A subjective units of distress scale (SUDS), incorporating a numerical scale for assessment of severity of intensity of emotions whereby 10 is the most severe and zero is the least (Dovey and Wilday, 2012). Sarah graded this trigger as an eight on the SUDS scale, which explained her avoidance of a return to work.
A graded exposure plan was formulated in order to achieve the SMART goal, enabling Sarah to enter her work premises. The exposure plan consisted of steps aimed at reducing her distress level.
Sarah maintained an exposure task record and SUDS diary with ongoing comments. She engaged very well throughout the process, culminating in an anxiety level of four out of 10 when she walked to the entrance of the building and was met by her manager. She gradually gained the confidence to overcome her reluctance to return as a result of this graded process.
She reflected on the significant reduction in her anxiety levels, recognising that this was the first step in her enabling herself to consider a phased RTW. Having managed to enter the workplace gave her confidence to take the next step of achieving a full RTW, accomplished in collaboration with her manager.
An effective return to her normal working hours and workload was achieved within a three-week period with the OH practitioner being on hand for further support. The success of this approach resulted from her active engagement with the behavioural and cognitive interventions and developing a good rapport between herself and the OH practitioner.
Airedale NHS Trust (2009). “How cognitive behavioural therapy and a stepped care approach to mental health was adapted and implemented for use in the Occupational Health Department”. NICE.
Beck AT, Emery G and Greenberg R (2005). “Anxiety disorders and phobias. A cognitive perspective”. 15th edition. Basic Books: United States of America.
Blenkiron P (1999). “Who is suitable for cognitive behavioral therapy”. Journal of the Royal Society of Medicine; vol.92, pp.222-228.
Butler G and McManus F (2000). “Psychology. A very short introduction”. Second edition. Oxford University Press: New York.
Dovey A and Wilday S (2012). “What is CBT?” Certificate in Cognitive Behavioural Skills for OH Professionals December 2011-March 2012, London
Hardy M and Heyes S (1999). “Beginning psychology. A comprehensive introduction to psychology”. Oxford University Press: New York.
McGinn LK and Sanderson WC (2001). “What allows cognitive behavioural therapy to be brief: overview, efficacy, and crucial factors facilitating brief treatment”. Clinical Psychology: Science and Practice; vol 8(1), pp.23-37.
Moorey S (1996). “Cognitive behaviour therapy for whom?” Advances in Psychiatric Treatment; vol.2, pp.17-23.
Wilday S and Dovey A (2005). “All in the mind?” Occupational Health, September, pp.25-28.