‘We have seen principles of CBT trickle down into the mainstream’

Dr Jo Daniels is Senior Lecturer in Clinical Psychology (University of Bath) and Academic Director on the university’s Doctorate in Clinical Psychology. She is also a clinical psychologist working in medical settings in North Bristol NHS Trust. She spoke to Ella Rhodes about the evolving role of cognitive behavioural therapy (CBT) in treating both mental and physical health conditions.

How has the role and importance of CBT within psychology evolved over the years?

The question is always, how far back do we want to go? If you look closely at philosophical movements such as pragmatism or to great thinkers, like Seneca and Descartes, you can see traces of the origins of CBT in philosophy, predating formal psychological enquiry in a form we would recognise. Were we always heading in this direction? 

While most look back to Beck in the 1960s as the arrival of CBT in clinical psychology as we know it, the recognisable foundations for CBT in psychology were firmly in place as early as the 19th century in early theories of emotions; for example, the James-Lange theory of emotion examined responses to our environment and how this affected emotion and physiology. As we moved through the years and the breakthrough of behaviourism which brought systematic desensitisation, and then the shifting emphasis moving to cognitive ‘interpretation’ as a key element to our psychological work, we see how CBT has evidenced a very strong history of empiricism in psychological science. CBT has an empirically-grounded foundation and solid theoretical basis that has stood the test of time, consistently producing evidence that is considered the best we have available. 

And CBT has continued to evolve in light of that scientific development?

Yes, constant research has ploughed into understanding the key processes that belie therapeutic change. Indeed, we have seen in ‘third wave’ therapies further degrees of theoretical evolution with emphasis placed on new and divergent ideas, such as ‘acceptance’ and values-based work (ACT) metacognitive processes (Mindfulness Based Cognitive Therapy and Metacognitive Therapy) or more emotional-interpersonal aspects (Dialectical Behaviour Therapy). It will be interesting to see where we go next with CBT. 

These are some of the reasons CBT has become prominent, perhaps ‘important’ in psychology. Some might argue that CBT has unequivocally earned its place at the table in our profession. However, there is space for more than one psychological modality at the ‘table’; CBT is only one approach, with many iterations! We know there are many other therapeutic modalities in psychological therapy. Our training and breadth of work as psychologists is so much broader, but due to the evidence base, CBT offers a great deal of credibility and opportunity to enable change.    

The evidence for CBT has also underpinned one of the largest expansions of psychological services that we have known: the advent of IAPT (Improving Access to Psychological Therapies) in England and Scotland. Psychological therapies are now more available than they have ever been. This has involved significant investment in the psychological workforce, with training in psychological therapies open to all those with a core profession. Alongside the BPS accreditation requirement to train all clinical psychologists in at least CBT, we can see that CBT has become core to the development and delivery of our profession… but it does not define us.   

Is CBT fully understood?

One of the misunderstandings about CBT, and where CBT diverges from psychology for some people, is the unhelpful myth that CBT is highly mechanical. The mechanics are pretty well supported in terms of the interplay between thoughts, feelings, behaviour and physiology; however, the role of emotion in psychological distress, and the delivery of CBT within the necessary context of an empathic, collaborative relationship, are both pivotal factors in the success of each single intervention delivered. Anyone who delivers CBT without accessing or working with emotion in a therapeutic way, is simply doing CBT wrong. CBT draws on so many more of our skills as therapists than just protocol adherence.  

Has the pandemic had any impact on the use of CBT? 

Much of the research that has emerged during the pandemic has reported high rates of psychological distress in the general public, with elevated rates in special groups such as those working on the frontline and those with pre-existing physical and mental health difficulties. Thankfully, we are in the fortunate position in the UK where we have strong evidence-based interventions, such as CBT, free and accessible to those who need it on the NHS, in formats that suit individual need. 

We have seen a surge in referrals and self-referrals to IAPT in response to the pandemic, but it is not just an increase in access to structured interventions that we have seen… there has also been a demand and proliferation of CBT-derived clinical advice which has made it into mainstream media. Much of  the work that has consumed my time over the course of the pandemic has centred around engaging the public in CBT ideas, shaped by research and informed by clinical practice, applying what we know to new problems. From ELLEmagazine to the New York Times, I have stood alongside others in our profession, sharing standard CBT techniques in bite-sized chunks using accessible language (see here for examples: tinyurl.com/y9h2tfvv) with the aim of reaching people who may be experiencing distress they attribute to the pandemic. 

Of course, three-minute soundbites in TV news interviews are not nearly sufficient to address the needs of those experiencing clinical levels of anxiety or depression. But it has been clear that highlighting ‘normal’ distress as a reasonable response to a novel and deadly virus is an important role for us as psychologists… and also to share, with those who need it, simple strategies that could help alleviate the worry and anxiety they were facing during the pandemic. 

So, in some ways we have seen principles of CBT trickle down into the mainstream media and general public in a way that we haven’t quite seen before. I think this can only be a good thing: we must keep working to destigmatise mental health by whatever means possible.

Over the pandemic I have also been struck by the fantastic work by OxCADAT, Covid response working group and IAPT, where high-quality clinician resources have been quickly adapted and made freely available to those working with the most distressed – these have been vital to clinicians over the pandemic. The BPS also mobilised to develop key documents such as The psychological needs of healthcare staff(tinyurl.com/eka84dmv) which has been influential in the Covid response outside of our own profession. The BPS Division of Clinical Psychology ‘Covid-19 Bulletin’ has been a useful means to disseminate working practices during the pandemic, allowing us to learn from one another.   

It has been a time of growth for our profession, under duress admittedly, but I think we should all be proud that we have been working to be part of the solution. 

Could you tell me about the use of CBT in physical health conditions? 

There is a fascinating history to the evolution of CBT in physical health conditions. Psychological ways of approaching the mind and body go back as far as the inception of psychology itself – indeed, there were fervent attempts to integrate psychology into medical training for a more ‘holistic approach’ around 1912… how might that have changed things? But the key foundations for CBT in physical health settings emerged in the 1970s. In this decade we saw the development of George Engel’s biopsychosocial model, the coining of the term ‘behavioural medicine’ at Yale University, and of course Beck’s groundbreaking cognitive theory of emotion. It was at this time that behavioural medicine (often used interchangeably with medical psychology, or clinical health psychology) was conceptualised as a key area for CBT to be applied to complex medical problems. 

As chronic illnesses became more common and people were living longer, there was a clear benefit for psychology to support people to adjust and manage long-term conditions where medicine could do no more (see Andersson, 1998, and Felgoisse, 2005, for more). Due to the underpinning principles of CBT as a time limited, goal-directed collaborative approach which fosters progress towards self-management, CBT is very well placed for use in physical health conditions. CBT engenders self-determinism and endorses a patient-led approach, which are important foundations for successful long-term self-management of physical and mental health. 

However, CBT for physical health conditions has not been without controversy. There are still pockets where CBT is misunderstood; historical assumptions that use of psychological therapy in physical health conditions implies symptoms do not have a pathophysiological origin. This is not the case, as humans we are more complex than that; we all respond to symptoms and illness differently, even when you consider the common cold, and psychology has an important role in optimising self-management. CBT is primarily directed at improving quality of life, increasing functioning and reducing distress; very often we see a positive impact on degree or presence of physical symptoms, however this is not the target of the intervention, just a welcome consequence. 

The evidence for CBT in medical conditions has been growing exponentially over recent years and clinical health psychology is one of the fastest growing areas of our profession. This is unsurprising because it is such incredibly rewarding work, and often we see interventions really transform lives. A meta-analysis led by Beth Fordham and published this year reported that CBT works to a greater or lesser extent for most groups that it is applied to. 

What type of physical conditions can CBT be applied to?

Chronic pain is considered the flagship for CBT in health, but there is evidence for the use of CBT in diabetes, irritable bowel syndrome, chronic obstructive pulmonary disorder, cancer-related fatigue, multiple sclerosis and many other conditions. How CBT is used with these conditions will vary and depend on the presenting difficulties; this could include developing new self-management strategies for symptoms, or working with accompanying worries or anxieties around health, which is very common. 

CBT can also be useful in medical settings for other issues such as needle phobia, supporting treatment adherence and preparation for surgery. The importance of psychology and CBT has been acknowledged through endorsements and recommendations of these approaches in NICE clinical guidance. 

CBT has really evolved over the years, with a proliferation of third wave therapies making their way into clinical health services, particularly MBCT and ACT. In recent history we have also seen IAPT expand to address the needs of those experiencing both psychological distress and physical health problems, the two of which go hand in hand of course, with more than half of those with long-term conditions struggling with mood and/or anxiety related issues. With an ageing population who are living longer with health problems, these evolutions mean we will have more to offer those in need. 

What’s the next challenge you see?

To expand the evidence base for psychology and CBT in medical contexts to ensure that we are using psychology where, when and most importantly, how it is most needed. I am committed to the notion of ‘normal psychology’ of illness, taking a non-dualist approach to working with physical health, improving our therapeutic accommodation of the ‘normal’ process of adjustment in newly diagnosed and fluctuating illness. It is now commonly accepted that CBT ‘works’ to a greater or lesser extent for most physical health conditions, but we know less about how it works, and this is a good direction for CBT to move in. 

How do you feel about becoming chair of the British Association for Behavioural and Cognitive Psychotherapies scientific committee? What will the role involve? 

I am delighted to be taking on this role with co-chair Simon Blackwell: we will make a great team. Between now and July 2022 we will be sitting as chairs elect, learning the ropes before taking the helm when current chair Professor Glenn Waller steps down. Both Simon and I have been part of the BABCP scientific committee and other international scientific committees for some years, and I think we are both looking forward to taking on this role, particularly as we are moving towards the 50th Annual BABCP conference – there is so much to celebrate. 

This new role will offer further wonderful opportunities to work with the greatest minds in our field to shape and develop future scientific programmes in a way that is responsive to advances in both research and clinical practice, delivering scientific conferences that are based on inclusive principles and innovative methods. There are of course key agendas to drive forward, such as meaningful collaboration with experts by experience in the dissemination of scientific knowledge, and ensuring that we, as a scientific committee and conference, reflect the diversity of the society we live in. 

I am particularly keen to strengthen the behavioural medicine stream… no surprises there! But I also feel quite passionately about creating platforms for emerging talent and early career researchers, the future leaders of our field. 

- Find Dr Jo Daniels on Twitter.

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