Challenges for CBT - What are the Evidence - Based Choices? Current challenges. How to translate research findings into practice?

Transcription

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? 1

2 Let s go back to basics Evidence based therapies: 3 critical components affect outcome 1. Clear structure of working What leads to good outcomes? Relationship 2. Focus on problems relevant to the person 3. Built on a relationship with the practitioner What leads to good outcomes? Relationship Structure of working An example: How does CBT work? Has anyone said. What you said last time really made a difference I.e. patterns of effective questions Plus teaches skills to make changes Key point: CBT has a structure and solutions that can make sense of symptoms A form of psychotherapy? All about teaching/learning Can be taught in different ways 2

3 Example: Classic CBT structure: Five Areas Assessment (Williams) Situations, relationships and Practical Problems Can the structure of CBT be offered in different ways? Altered Feelings Altered Thinking Altered Physical Symptoms 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. Altered Behaviour Key principles: choice of LI CBT approaches? Evidence based Accessible Avoid Information overload Stories/Questions Clearly presented Usable. 25% of people struggle to read at reading age 11 The right language: Martinez et al (2008) Book Title Reading age (average: adult health care) 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 Overcoming depression and low mood: a five areas approach (2 nd Edition) - Williams (2006)

4 Resources that engage- Who? Overview: Evidence based working 100 % 50-60% Non Specific factors 100 % Evidence based working Evidence based model e.g. CBT Evidence based working Much focus here in training courses and guidelines Non Specific factors Very Specific factors Relatively less focus here 4

5 Are all talking therapies pretty much the same? Claim is non-specific factors are the most important aspect relationship is key - YES Also: It doesn t matter what form/model of therapy is then offered they are all the same TESTABLE Some key questions Is Cognitive Behavioral Therapy the Gold Standard for Psychotherapy? The Need for Plurality in Treatment and Research JAMA: Leichsenrig and Steinert Sept 2017 Published online September 21, doi: /jama Cuijpers P, Cristea IA, Karyotaki E, Reijnders M, Huibers MJ. How effective are cognitive behavior therapies for major depression and anxiety disorders? a meta-analytic update of the evidence. World Psychiatry. 2016;15(3): What they found Cochrane risk of bias tool: only 17% (24 of 144) of RCTs were high quality CBT cf waiting list condition >80% studies (anxiety) 44% (depression) High-quality studies: CBT was found to be less efficacious than in low-quality studies High-quality studies, CBT achieved large effect sizes only in comparison with waiting list conditions. Cf with TAU effect sizes were only small to moderate ( ). In panic disorder, CBT was not more effective than treatment 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) 5

6 Patient/person preference is also part of the mix 2 year follow up of our original Lancet Cobalt paper People still using CBT approaches were people for whom it made sense Wanted to take an active part in self-therapy Those not still using it preferred to tell their story Some further challenges to what is offered ccbt can make you worse (OCTET trial) ccbt can be very disappointing even for depression and anxiety Farrand and Woodford: Shorter/minimal LI support for guided CBT gives 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? Evidence based working Structure of working Not based on severity alone 6

7 Accessing help The Inverse Care Law 1 Care Access and distance Travel or Parking issues 7

8 Even harder when you have a LTC e.g. pain, stroke, angina, COPD Anxiety and depression make it even harder Let s look around the room Jargon cuts people out Cognitions Dysfunctional Negative reinforcement Can baffle people, perplex, baffle or make them feel stupid It s a lot to ask.. Key concepts: Information overload Prior learning 8

9 Assessment with a purpose Our joint assessment Evidence based working Maximising relationshiop/ support What s our therapeutic role? Professional? Practitioner? Teacher? Supporter? Coach? Motivator? Encourager? Working your Mojo (using the relationship) 9

10 How much and what type of support? The Importance of Support? Support matters but how much? LI 213 patients a year cf HI 72 per year LI typically 5 sessions cf HI 12 sessions Not at all clear higher depression scores alone means LI not appropriate (Farrand/Woodford) Cuijpers et al (2013) - equal results for guided CBT and HI interventions What does this mean in practice? Are we asking the right questions in allocating to therapy? NICE deals with studies grouped data What about at an individual level? Let s go away on holiday together. Focus more on process 10

11 Do a learning assessment How do you like to learn? How do you want to work? Perhaps the issue is also very much about engagement and maintaining motivation to change It s hard to change: Remember January... Plan, Do, Review approach 11

12 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 relationship RCT study designs/evidence and consider pragmatic implementation How to retain the strengths/benefits of structured approaches: Training Manualised models Supervision Relationship Personalisation: EHIC and ETIC Etic approaches assume universal presentationsdepression is depression and depression treatments are what is needed Emic: local cultures matter Cultures differ across the UK and across local communities Cultural adaptations are needed Language matters psychological mindedness 12

13 Summary: Solutions to the dilemmas 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 Any questions? Chris.williams@glasgow.ac.uk Does it work?