Volume 47 Number 2 • May 2019
Drawn to Help Page 15
BABCP Imperial House, Hornby Street, Bury BL9 5BN
contents
Tel: 0330 320 0851 Email: babcp@babcp.com www.babcp.com
Volume 47 Number 2 May 2019
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Welcome to the latest issue of CBT Today. Thanks to everyone who entered the discussion online and on social media about our 'Frankenstein' article in the February issue. While this time around we might not be as contentious, we hope that the features included here provide equal food for thought. As always, thanks to all our contributors.
Main Feature 15 Drawn to help Michael Safranek shares his creative instincts for providing CBT resources
Features 8
If you have any ideas for inclusion in the magazine please just drop me a line. Peter Elliott Managing Editor peter.elliott@babcp.com
Contributors
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Linda Bean, Michelle Brooks, Andrew Beck, Maja Jankowska, Marcia Manderson, Mabel Martinelli, Saiqa Naz, Kevin Perkins, Michael Safranek. CBT Today is the official magazine of the British Association for Behavioural & Cognitive Psychotherapies, the lead organisation for CBT in the UK and Ireland. The magazine is published four times a year and posted free to all members. Back issues can be downloaded from www.babcp.com/cbttoday
Disclaimer The views and opinions expressed in this issue of CBT Today are those of the individual contributors, and do not necessarily reflect the views of BABCP, its Trustees or employees.
Next deadline 9.00am on 17 September 2019 (for distribution week commencing 11 October 2019)
Advertising For enquiries about advertising in CBT Today, please email advertising@babcp.com. © Copyright 2019 by the British Association for Behavioural & Cognitive Psychotherapies unless otherwise indicated. No part of this publication may be reproduced, stored in a retrieval system nor transmitted by electronic, mechanical, photocopying, recordings or otherwise, without the prior permission of the copyright owner.
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May 2019
Should we make happiness central to the CBT agenda? Mabel Martinelli asks if therapy should be about making people happy
12 The IAPT Black, Asian and Minority Ethnic Positive Practice Guide Members of the BABCP Equality & Culture Special Interest Group were instrumental in updating IAPT's latest BAME Positive Practice Guide 18 Supervision: Stay or go? How do you go about changing your clinical supervisor? Linda Bean and Kevin Perkins look at your options 22 Leave your fear at the door Marcia Manderson talks about helping men deal with the pain of sexual assault
Also in this issue 4 6
Latest news from BABCP Accreditation updates
BABCP Conference and Workshops 2019 University of Bath, 3 – 5 September Confirmed Keynote and Workshop speakers include: Susan Bogels, University of Amsterdam, the Netherlands David A Clark, Beck Institute of Cognitive Behavioural Therapy Georgina Charlesworth, University College London Kate Davidson, University of Glasgow Jaime Delgadillo, University of Sheffield Windy Dryden, Goldsmiths University of London Thomas Ehring, Ludwig Maximilian University of Munich, Germany Jonathan Green, University of Manchester Gillian Haddock, University of Manchester Peter Langdon, University of Kent Stephen Kellett, University of Sheffield Richard McNally, Harvard University, USA Ailsa Russell, University of Bath Glenn Waller, University of Sheffield Chris Williams, University of Glasgow
Now confirme d Special event on Tuesday 3 Sep tember Revolution in M ental Health Service Deliver y: The Evolution o f Low Intensity CBT Early Bird reg istrations end 12 July
Download the Conference Provisional Programme and to register, go to www.babcp.com May 2019
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Specialist mental health
support for new mums
England
available in every part of England As many as one in four women will experience mental ill-health during pregnancy or in the two years after birth, covering a wide range of conditions and different degrees of severity. It is estimated that as many as one in 500 women may experience postpartum psychosis, one of the most severe forms of mental ill-health affecting women in the perinatal period. NHS England recently announced that new and expectant mothers across the country can now access specialist mental health care in the area where they live. The landmark rollout of specialist perinatal community services across the whole of England, means that mums and mums-tobe who are experiencing anxiety, depression or other forms of mental ill health should be able to access high quality care much closer to home. Five years ago two in five parts of the country had no access to specialist community perinatal mental health treatment, but there is now full geographical coverage for the first time, with services in every one of the 44 local NHS areas, and plans to develop them further.
The NHS Long Term Plan also sets out a raft of new measures to improve care for new and expectant mums and their families, including: Making specialist community-based care available from preconception to two years after birth rather than one. Evidence suggests this is the most critical time in a child’s development and the period when infant separation anxiety can peak and may trigger a relapse of mental health difficulties, along with other changes in women and children’s lives. NHS England has already funded four new Mother and Baby Units (MBUs) in areas of the country which historically struggled to access specialist inpatient services close to home. Mother and Baby Units (MBUs) support women who are experiencing the most severe forms of mental ill health to stay with their babies, helping them to bond at a critical time, while receiving around the clock care, treatment and support. All four new MBUs are now offering care – three eight bedded units have opened in Kent, Lancashire and in East Anglia, with a further unit in Devon open.
The expansion comes alongside the opening of four new mother and baby units, which mean that the most seriously ill women can receive residential care without being separated from their babies in every region.
Reading Well BABCP regularly partners with Reading Well, an organisation who produce booklists on different health topics in discussion with health experts, people with experience of the health conditions and their relatives and carers. These lists are available in libraries to be easily accessible. Reading Well are currently working on a new list about mental health for 7-11 year olds. If you have titles you want to recommend you can contact georgia.newman@readingagency.org.uk You can find out more about Reading Well at https://reading-well.org.uk/
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May 2019
Correction In our last issue, we featured ‘There’s something wrong with our pipeline’ by John Barber. The editing process inadvertently removed the relevant references, which are listed below. 1. Garland A.F., Plemmons, D. and Koontz L. (2006). Research-practice partnership in mental health: lessons from participants. Adm. Policy Ment. Health & Ment. Health Serv. Res. 33: 517-528. 2. Bergljot, G, Tickell, A., Baer, R., O’Neill, C. and Crane, C. (2018). Mindfulness and clinical science. The Psychologist December edition.
news
Participants needed! BABCP-accredited CBT therapists are needed for research into their experiences while working with clients who are suffering from Bulimia Nervosa. This will mostly focus on investigating the aspects of CBT practise which are most effective as well as exploring therapists’ opinions on changes they would recommend in order to increase long-term effectiveness of CBT. The interview should take approximately an hour and will be audio-recorded. Participation is voluntary. The researcher, Chrysanthi Menegaki, is completing the Master of Science in CBT at the University of Bolton. If you wish to take part in the study or want more information, please email Chrysanthi Menegaki at chrysanthi_menegaki@hotmail.co.uk
Students enrolled at UK universities are needed for a study on a recently-developed ACT self-help program. Participation involves completing a range of questionnaires and 12 online ACT modules free of charge. If you are aged 18 or over, enrolled at a UK university and want to know more, email Holly Conheady at holly.conheady.1@city.ac.uk
At the beginning of this year the World Confederation of the Cognitive and Behavioural Therapies was launched. This Confederation joins together six regional associations across the world (AACBT, ABCT, ABCTA, ALAMOC, EABCT, and IACP) with the aim of addressing global issues and communication in relation to the development and practice of CBT at a worldwide level. As a member association of EABCT, BABCP becomes part of this confederation and hopes to play an important role. The regional organisations had already been working closely together since 1995 as a World Congress Committee (WCC) which has ensured the effective planning of world congresses and their role in promoting the dissemination of evidencebased principles and practice of cognitive and behavioural therapies including the forthcoming 9th World Congress in Berlin in July. The Mission of the confederation is to be a global multidisciplinary organisation dedicated to the promotion of health and wellbeing through the scientific development and implementation of evidence-based cognitive behavioural strategies designed to evaluate, prevent, and treat mental conditions and illnesses. It aims to: • Support the development and profile of Cognitive and Behavioural Therapies (CBT) Worldwide • Support the development and profile of Cognitive and Behavioural Therapies (CBT) Worldwide • Develop a Worldwide Network to Share News, Information, and Issues in CBT • Promote and advocate for mental health, CBT and Evidence based Treatments for Psychological Disorders in order to Improve Wellbeing across the Globe • Develop and Support Effective Implementation of CBT through Training
• Facilitate and Support Research in CBT Sarah Egan (Australia) is the current President of WCCBT and the Board consist of two representatives from each of the six member associations: Association for Behavioral and Cognitive Therapies (ABCT) – Keith Dobson (Canada) and Lata K. McGinn (USA Asian Cognitive Behaviour Therapy Association (ACBTA) – Firdaus Mukhtar (Malaysia) and Ning Zhang (China) Australian Association for Cognitive and Behavioural Therapies (AACBT) – Sarah Egan and Ross Menzies (Australia) European Association for Behavioural and Cognitive Therapies (EABCT) – Rod Holland (UK) and Thomas Kalpakoglou (Greece) International Association of Cognitive Psychotherapy (IACP) Lynn McFarr (USA) and Mehmet Sungur (Turkey) Latin-American Association of Analysis, Behavioral Modification and Cognitive and Behavioral Therapies (ALAMOC) – Luis Oswaldo Perez and Edgard Pacheco (Peru) The World Confederation of the Cognitive and Behavioural Therapies will be formally launched at a General Assembly to be held during the 9th World Congress of Behavioural and Cognitive Therapies in Berlin, Germany between July 17 - 20 2019. For further information visit the Confederation website at www.wccbt.org
May 2019
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Taking a Break?
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If you are not practising CBT you are not expected to demonstrate supervision or CPD during this period.
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May 2019
Many accredited members will take an extended break from practice for a variety of reasons. We are happy to support this by allowing you to stay accredited during this period for up to two years, but it is important that you let us know that you are off – what we call a Leave of Absence, for Accreditation purposes, even if you are still working in some way. Reasons for a leave of absence will include: • Maternity or childcare • Health • Study • Carer roles • Change of job role (eg clinical lead with no caseload) • Travel • Practising CBT abroad (this is still considered as a leave of absence for Accreditation purposes as BABCP Accreditation is of current practice in the UK, its territories or Eire) • CBT is not your main psychotherapeutic modality If you stay out of practice for any of these reasons (or any other except upheld disciplinary findings)
you may stay accredited for up to two years. After that, we would ask you to lapse your Accreditation, but it is a very easy process to reinstate when you return to practice. Whatever the reason, it is important that you let the Accreditation team know as we may need to adjust Accreditation or Reaccreditation dates. If you have time out after receiving your Provisional Accreditation but before submitting your Full Accreditation, we will extend the due date for this. If you are not practising CBT you are not expected to demonstrate supervision or CPD during this period. Time off and Reaccreditation You should not make your Reaccreditation Declaration if you are on a Leave of Absence. If you are on a Leave of Absence on your due date, you will remain accredited and be invited to reaccredit on the same date the following year. If you have been out of practice for a period during the twelve months prior to making your
accreditation declaration, you can still submit it provided that you are back in practice on your reaccreditation due date. If you are selected for Random Audit of Reaccreditation having had time out of practice in the previous twelve months, you can explain this on the audit documents. You will not be expected to demonstrate any CPD or supervision for the time you have been out of practice. You should, however, be in practice at the time of the audit. More information can be found on the Reaccreditation pages of our website.
Retiring but still have much to offer? Newly-retired practitioners can prov ide a wealth of experience to potential supervise es and trainees, so we are now pleased to be opening our Extended Practitioner Accreditation to all retiring members offering valuable CBT supervision or training in any setting – either privately or within any institution. Generally, members must be in CBT clinical practice to remain accredited, so retir ing practitioners will normally have noti fied BABCP of the end of their practice. Althoug h their Accreditation would have lapsed, they may still choose to maintain their interest in CBT through the benefits of BABCP mem bership. Now, however, Extended Practitioner Accreditation allows all members who continue to offer supervision and/or training to remain accredited for up to two years after they permanently give up their practice.
to keep your hand in and maintain your clinical skills. Two client-facing CBT hours a week is sufficient to be considered in practice for Accreditation purposes. So a small private practice might meet your needs and also allow you to stay accredited. Any practitioners who are taking a temporary break from practice should notify the accreditation team of a Leave of Abse nce. Extended Practitioner Accreditation – the Criteria • you must be providing CBT supervisi on and/or training in any setting • you must be permanently ceasing, or retiring from CBT clinical practice • you must be a BABCP Accredited practitioner • maximum duration: two years, afte r which you will be asked to lapse your accredit ation Making an Application
This will benefit any of their supervise es who are maintaining or working towards Accreditation as their supervisors shou ld either be BABCP Accredited practitioners , or, where this is not possible, they should mee t the criteria for Accreditation, including being in current practice.
Further good news is that there are no application forms. Simply email accreditation@babcp.com with the subject line “Extended Practitioner Accreditatio n”, stating when you ceased clinical practice.
Alternatively, whilst you may be hap py to wave farewell to the institution to which you have devoted many years of your life, you may wish
Please provide information on how many hours of ongoing practice in supervisi on and/or training you expect to be prov iding and in which setting.
May 2019
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Should we make
HAPPINESS central to the
CBT Agenda?
If your CBT practice resembles anything like my own, you will find most clients coming to you saying all they want is “to be happy�, says Mabel Martinelli
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May 2019
feature And if your CBT training was anything like my own, you will have helped them reframing their wishes into Specific Measurable Achievable Realistic and Time-bound (SMART) behavioural goals. But have we got it all wrong? Should therapy rather be about making people “happy”? And are we CBT therapists the best practitioners to help clients achieve that? It could be argued that the aims of CBT therapeutic interventions were historically broader than what they are nowadays. With greater time constraints, the current agenda is often dictated by the identification and modification of the source of suffering. Or perhaps even more specifically by establishing how closely a presentation aligns with diagnostic criteria. The last decade of CBT practice in the UK has been influenced by the IAPT model of practice, with specific treatment protocols, and a need to work closely with mental health problems within the time restrictions of a measurable and efficient NHS service. But what if we have it all wrong, and happiness is in fact the key area to focus on and not just a by-product? The revolutionary Increasing Access to Psychological Therapies (IAPT) programme was inspired by collaboration between an economist and a CBT therapist. Lord Richard Layard said to have always believed, like the 18th Century Enlightenment, that societies should be judged by the happiness of the people. In his work, he stresses the role of mental health and argues that psychological treatments ought to be more widely available. The CBT arena was in a good place to provide evidence-based/disorder-specific approaches, and in close collaboration with David Clark, the programme became what it is now. Layard and Clark went further than theory and practice, to articulate the case for a national
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It has become apparent that all those years of focusing on the negative have a lot to tell us in terms of what brings us suffering, and indeed how to remove suffering, but very little in relation to what makes us happy.
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investment into increasing access to psychological therapies. As this movement started and gathered momentum in the field of mental health, the case for happiness was being defined elsewhere. In economic terms, a shift occurred from measuring countries according to Gross Domestic Product (GDP) to developing an actual measurement of the level of happiness of the population (Gross National Happiness - GNH). Since 2012 yearly happiness indices have been produced, globally with the World Happiness Index, regionally with the European Social Survey, and nationally with the UK as one of the first countries officially monitor this measure. Layard’s work was followed by the Action for Happiness programme, advising the UK population on specific actions to improve their overall sense of happiness and wellbeing. In the broader psychological community, Martin Seligman was elected President of the American Psychological Association and proposed a shift from studying ‘negative’ psychological states to ‘positive’ states, giving birth to the ‘Positive Psychology’ movement. It has become apparent that all those years of focusing on the negative have a lot to tell us in terms of what brings us suffering, and indeed how to remove suffering, but very little in relation to what makes us happy. There also seems to be an unspoken assumption that by Continued overleaf
May 2019
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People who are perceived as ‘happy’ also have a greater positive social impact, being more likely to have supportive social networks and be trusted by other people.
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10 May 2019
Should we make
HAPPINESS central to the CBT Agenda? Continued
removing ‘suffering’ we can somehow spring into ‘happiness’, but is this necessarily the case, and has CBT fallen into this trap? Recent research in many areas of study from economics to positive psychology estimates that simply experiencing happiness will have significant positive repercussions for you. When assessing ‘happiness’, apparently the most important measure is self-report. The main life evaluation question asked in economic polls is what is known as the Cantril Ladder:“Please imagine a ladder, with steps numbered from 0 at the bottom to 10 at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you. On which
step of the ladder would you say you personally feel you stand at this time?” Take a moment and ask yourself that question. How did you score? Apparently, according to a significant body of positive psychology research, if at any moment in life you are feeling really happy, as measured 8 or 9 on a 10-point Likert scale, that would add anywhere from five to seven years on to your life expectancy. Data relating to physical health also points to greater physical benefits. A report of greater happiness in everyday life correlates highly with the presence of fewer chronic pain conditions, lower likelihood of diabetes, fewer strokes, a better chance of survival following a diagnosis of cancer, a better cardiovascular and immune profile and a lower
likelihood of suffering fatal accidents. The positive effects also correlate with positive social health. Children who describe themselves as feeling ‘happy’ have better relationships with peers, a wider circle of friends, are judged to be warmer and more intelligent, and less selfish. People who are perceived as ‘happy’ also have a greater positive social impact, being more likely to have supportive social networks and be trusted by other people. They are less likely to experience divorce and report greater fulfilment in marriage. The benefits also translate into the work environment: it has been suggested that happiness and positive emotions actually make you more creative and innovative at work. The research is promising, and the demands from clients would suggest that the need is there. But are we CBT therapists the best practitioners to do it? A glance through the positive psychology literature and interventions - Values Work, Mindfulness, Positive Data Logs (Gratitude Journals), Compassionate Approaches and use of Imagery - would look familiar to most contemporary practitioners. I wonder, then, if the need is for a shift in focus, rather than perspective? Perhaps the next time a client tells us “I want to be happy”, we should say “Yes, let’s help you be exactly that”. Layard’s work was about ‘Happiness’ after all. Mabel Martinelli is a BABCP-Accredited CBT therapist and Supervisor May 2019 11
The IAPT Black, Asian and Minority Ethnic
Positive Practice Guide
On the 11 April more than a hundred delegates attended the launch of the IAPT BAME Positive Practice Guide in London. This event was organised to tie in with the BABCP Spring Conference which had a particular emphasis on the contexts in which we work as therapists. The Positive Practice Guide (PPG) has been commissioned by NHS England to update the 2009 Guide and a team of BABCP Equality & Culture SIG members led by Andrew Beck developed the winning bid to produce the guide which has the full endorsement of the BABCP President and Board. Professor David Clark opened the event, reminding delegates that since the start of IAPT, thinking about the needs of BAME communities has been a central part of the ethos of the project. He was able to report figures released that day showing that although rates of access and outcomes to evidence-based mental health care had been improving year on year that there was still clearly room for improvement. Professor Clark has written the introduction to the guide and provided formative feedback to the authors to ensure it best meets the needs of services working to improve access and outcomes. BABCP President Professor Paul Salkovskis followed this introduction with his thoughts about how the organisation was delighted to support the guide and recognising the importance of improving the way we adapt therapies for BAME communities and the need to improve access to psychological therapies for communities who have been historically poorly served. One of the things that has characterised Professor Salkovskis’s time as President has been his support for work in the BABCP that improves the way that therapists and organisations consider diversity and he has ensured a high level of support for the guide at Board level. Andrew Beck provided an overview about how the guide developed, which involved consulting with 50 service users from a wide range of BAME 12 May 2019
feature this with Dorota, a Polish service user who had used IAPT services. They reminded delegates that Polish was now the second most spoken language in the country (after English) and that this community may have very different expectations of therapy and mental health services than most communities.
backgrounds and over 15 organisations who deliver mental health care specifically to BAME communities. He identified three virtuous cycles that organisations can develop as a result of using the guide to improve staffing, community engagement and therapy delivery. Saiqa Naz, BABCP Equality & Culture SIG Chair, developed the theme of community engagement and used examples from her own tireless work to show how a creative approach to working with communities showed that they were not ‘hard to reach’ as there was a great enthusiasm for knowledge about mental health in these communities, but that they were easy to ignore by stretched services who did not want to put in the work needed to improve access. Siaqa was joined by Abdikarim, a service user from a Somali background who gave a very moving account of the way that his education and career prospects had suffered as a result of social anxiety. Delegates were left visibly moved by his story of how CBT provided by IAPT had helped him to overcome his anxiety and begin to work towards his goals I life again. Debbie Roe from Touchstone in Leeds talked about the excellent work her service has done to improve access and outcomes for BAME service users in their region. Her service is used as an example of excellent practice in the guide because of their outreach work, provision of culturally adapted Behavioural Activation for Muslim Service Users and specialist low and high intensity therapy projects for refugees and asylum seekers. Michelle Brooks talked about the work that IAPT services needed to do in order meet the needs of asylum seekers and refugees in England. She reminded delegates about the unprecedented scale of people seeking refugee and asylum in
England and the higher mental health needs that these communities face as well as the social stresses they are under whilst awaiting decisions about their asylum claims. She introduced delegates to the ways that the guide will support services to adapt the way they work to meet the needs of these communities and support them in ways that go beyond the work done in the therapy room. Michelle supported Ali, an asylum seeker who has been helped by IAPT services, to attend. Ali talked eloquently about his experiences of seeking and finding help at an extremely challenging time in his life. Hearing first hand from someone in that situation brought home the importance of services being accessible and effective at times of crisis. Ali had felt so strongly about the need to convey this message to mental health staff that he attended even though he had found out that day that he was about to be made homeless the next day due to the ‘hostile environment’ that many people now face. Lastly Maja Jankowska talked about meeting the needs of the Polish communities in England. She co-presented
They talked about the frustration many Polish service users expressed in focus groups during the development of the guide around waiting times, lack of clarity as to what to expect and a lack of choice in terms of therapy support compared to what they might expect in Poland. She also highlighted that this community was not an easy one to engage with as it is geographically spread out and does not have a network of community hubs and religious organisations that many BAME communities may have. Hearing Dorota talk about how language barriers meant that very impairing mental health problems were unidentified and untreated for many years really emphasised the devastating impact that reduced access can have on people’s lives. Although the reports from Professor Clark, Professor Salkovskis and the project team were inspiring there was no question that the most important voices that evening were those of three service users who attended. Their testimonies about the barriers to treatment they had experienced and the life changing improvements they eventually benefited from as a result of IAPT services left delegates visibly moved and inspired to take the importance messages of the guide back to their services. A northern launch event will be announced soon and the executive summary, full guide and slides from the launch will be available on the BABCP website after it has been released by NHS England.
This article was written by project lead Dr Andrew Beck and project team members Saiqa Naz, Michelle Brooks and Dr Maja Jankowska. With special thanks to Professor David Clark, Professor Paul Salkovskis and Debbie Roe for presenting and supporting the project and especially to Abdikarim, Ali and Dorota whose thoughtful and moving testimonies emphasised the real importance of the guide. May 2019 13
14 May 2019
feature Some time ago when working as a PWP I carried out a triage assessment with someone who was having a difficult time. I was encouraged that his problems were treatable, but concerned that previous CBT had been unsuccessful. When I asked him about his previous treatment he told me that he had dyslexia and “the CBT was all read this, write that, and I couldn’t do it”. And this got me thinking. We don’t need all these words.
Drawn to help Improving Access to Psychological Therapies is not improving access for many of the people it is meant to serve, says Michael Safranek. For patients, there are multiple barriers to accessing treatment, and we should be thinking more creatively about how to remove these barriers.
The traditional delivery of CBT involves clients reading psychoeducational materials and keeping diaries. This is especially true at the Step 2 level in IAPT where people are supported in engaging in self-help materials. However, some people find it difficult to engage in written CBT materials for various reasons including not having English as a first language, dyslexia, learning disabilities, stroke, or other factors. I know from my own experience that trying to adapt treatment to meet the needs of these people can be time consuming for therapists and can mean making compromises. Within CBT are a range of highly effective behavioural interventions. If we illustrate these behaviours, then we don’t need any words. This creates a resource that can be used with patients who have difficulties with traditional text-based resources. That way therapists can have access to a single resource they can use across all these client groups, and clients have access to good quality evidence-based materials. When I had this idea it seemed so obvious I was sure such products already existed. However, despite extensive searching, I was unable to find anything that was aesthetically or clinically in line with what I
May 2019 15
feature
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I think of comics as an entirely different medium with a unique set of strengths that can be especially useful to us as therapists.
� 16 May 2019
imagined. While there are some excellent autobiographical graphic novels about living with a mental health problem, and a few that cover psychoeducational material, there’s nothing that really looks like a treatment manual or workbook. I started doodling and sketching out some ideas, but I have very little artistic skill. After a few dead ends I was put in touch with Mark Bennett, a fantastic graphic designer who clearly had a shared vision of how this would look. He turned my stick men and scribbles into beautiful clear pictures. We were offered some funding and put together a progressive muscle relaxation worksheet. It was an interesting process because it was obvious from some of the early illustrations that the written instructions given to patients were open to some misinterpretation. Our initial funding then fell through, but with the
progressive muscle relaxation worksheet as an example I eventually secured more funding to pay Mark and we produced two workbooks for sleep and panic. About a year ago I set up a website to share the workbooks, and then set about spreading the word on social media. Very quickly I started getting enthusiastic feedback. Messages came in thick and fast via the website from people telling me the resources were very useful, and over the past year lots more people contacted me echoing those initial comments. It is great for me to think that there are people being helped who otherwise may not have struggled, and it seemed like my suspicion about an unmet need was correct. But I think there is even more potential. There have been a number of studies looking at the use of comics for educating people about a
feature range of health or science issues. Matteo Farinella, author of Neurocomic, has moved into researching the use of comics for science communication. He found that when comparing the same science information presented in either a textbook or in comic format, there is no difference in knowledge acquisition. However, especially for people with less science background, comics perform better at engaging readers. And I can’t think of anyone harder to engage than the highly anxious or severely depressed. While the materials I developed are pitched for people who may have difficulty reading or writing in English, I don’t think of comics as being inferior to text, something that should only be considered as a second choice if someone is unable to read. I think of comics as an entirely different medium with a unique set of strengths that can be especially useful to us as therapists. Comics have a means of communication that is different to other mediums. A lot of information can be put across though page layout, panel shapes and sizes, framing, colour, and many other subtle tools. And a simply designed character can allow the reader to project themselves into the story, and visualise themselves engaging in the behaviours being modelled. It feels to me that information can be conveyed, but with less of a cognitive load. In recent years CBT has had a welcome expansion of digital resources and there is now a multitude of apps, computer programmes and websites, all supported by research grants and digital initiatives. While these tools are undoubtedly useful and valuable, the tools we have do not work for everyone. The barriers to accessing and engaging with treatment faced by patients are diverse, and we should diversify the ways we tackle them, and build up all the tools available to us.
I’m not sure what is going to happen next for Therapy Comics. I’m proud of the work I have done, but creating the workbooks in my spare time has been slow. I have also struggled to have the positive feedback I’ve had backed up by hard data. But right now my main priority is completing the High Intensity CBT training course that I am on. Other than retweeting things about mental health, comics, or occasionally both, Therapy Comics is on hiatus until the course is over. I am still gathering lots of ideas, sketching and doodling, and I’m hoping to have some more time and more money to turn that into some more useful workbooks and resources soon.
Michael Safranek
Mark Bennett
Michael Safranek’s Therapy Comics is at www.therapycomics.com. You can follow him on Twitter @TherapyComics All images featured here are © Therapy Comics May 2019 17
Supervision:
Stay or go?
Do we need to change our supervisor? Linda Bean and Kevin Perkins discuss the complex and somewhat vexed question of why and when and if and how this might need to happen `There are many practical circumstances that dictate a change of supervisor: training in a new modality, working with a different client group, changing job or starting in private practice. However, we are concerned here with considering a change of supervisor for altogether different reasons, reasons that may feel quite nebulous and difficult to pin down. By this, we mean other factors that might invite us to contemplate change or even compel us to stay, against our better judgment.
Think and consider Our starting point has to be consideration of what we bring to the table as supervisees. How do our previous experiences impact our expectations and interactions? It can be an illuminating process to construct a timeline of our previous supervisory
experiences, noting the gender, ethnicity, age and other salient identifying features of the supervisor, the quality of the relationship and whether there was conflict. Perhaps there are links to our childhood experiences of learning/power/nurture/conflict. This process might highlight issues to address, either in supervision or in personal therapy. We can then begin to explore what the supervisor does that is so difficult. Feedback from supervisors about incompetence (a necessary gatekeeping function) can be very distressing. It can also be hard to tolerate feeling incompetent, especially if it is related to an additional training for us when we are experienced, previously ‘competent’ therapists. Not only that, but the style of supervision may be very different. For instance, the supervisor may need to be more directive in the early stages of learning. In addition, working in a modality such as the more structured CBT, the new supervision may feel to us, and be, very different from that of a psychodynamic or person-centred supervisor. More worrying, however, is the presence of a disinterested supervisor who appears bored, rushes through the work, frequently cancels meetings and/or brings their own concerns and stresses into the supervisory space. This can result in a lack of rigour in the appraisal of client work, the undermining of supervisee confidence and, when problems arise, the complete absence of the vital restorative function supervisors provide. It may well negatively impact work with clients and lead to questioning of the supervisor’s fitness to practise.
What is missing? This leads us to explore what is not occurring in supervision that we may reasonably expect to be provided if supervision is to be ‘good enough’.
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feature While the following list is not exhaustive, it may kick-start our thinking about what is missing from our supervision.
A good-enough supervisor: • has up-to-date skills, knowledge and expertise in our therapeutic modality • can speak about differences in thinking and approach in a spirit of enquiry and non-judgment (especially if from a different therapeutic modality) • validates our work and challenges both thinking and practice • conducts meetings in an atmosphere of respect, openness and curiosity that encourages our development1 • demonstrates attunement to us • maintains boundaries and focus • canvasses for and accepts feedback. An area that is often overlooked is the presence of difference between supervisor and supervisee, whether it be in terms of age, class, race, religion, gender, sexuality, disability, pregnancy or maternity. The lack of acknowledgement of power and difference in the supervisory space can provoke a strong and sometimes painful response. Elaborating what these omissions mean to us will help us communicate our legitimate concerns. A crucial factor in resolving ruptures and difficulties in supervision is the willingness of both parties to address their contribution to the process. Both must be willing to take responsibility for their part in the shared communications and the constructions they place on the material. However, if the power differential or the rupture feels too great, it may be both necessary and desirable to seek an external space with a third party to think and reflect upon the experience of the process of supervision, the relationship with the supervisor and obstacles to resolution. This can be very helpful in clarifying thinking, needs and concerns, and planning a way forward.
The harmful one But when does supervision change from being imperfect to either inadequate or harmful? Undoubtedly, it happens more often than we would like to think. Ellis et al’s2 survey of three hundred and sixty-three US health professionals found that more than fifty per cent of them had experienced harmful supervision (this included unwanted sexual attention and public humiliation). More worryingly, the authors concluded that over half of respondents may have unknowingly experienced inadequate or harmful supervision. They asserted that many supervisees do not know their rights or what good supervision looks like. For this reason, in case it’s helpful, we have indicated
some further reading at the end of this article. We cannot underline strongly enough how difficult it can be to describe clearly and distinctly at which point the supervisory relationship has developed, or could develop, into a quasi-therapeutic relationship or a close personal, sexual or abusive relationship. It can feel very isolating when this happens, and often we blame ourselves, even though the responsibility lies with the abuser. If this is our situation, then it’s imperative to seek advice and support from our accrediting body/trade union/employer. Termination of the supervisory relationship in these circumstances is the only course of action, both for our protection and that of our clients. Undoubtedly, this is much harder if we are a trainee or in our first post and we are relying on our supervisor for a good reference. Nonetheless, concerns about professional practice, compliance with standards of professional behaviour, and of morals and ethics cannot be avoided.
Making the change That apart, what do we do if we believe there is an impasse and we just need a different supervisor? This can be tough if we believe that we cannot alter or leave our current supervision arrangements because we are in training or in a new post. Nevertheless, some employers/training institutions may be amenable to us changing supervisor. Others may see remaining in the situation as a part of the learning process. While the latter approach can seem harsh, there is nevertheless always value in exploring what is contributing to our desire for change. On top of all this, the lack of availability of supervisors specialising in work with children and young people, either because of geographical location or specific modality requirements, further limits choice, and may inhibit necessary change and force unhelpful compromises. In these circumstances, it may be worthwhile to consider Skype or telephone supervision if it can give you access to a wider range of suitable supervisors. Continued overleaf
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Leaders have problems every day but discuss them less than they ought to. Many leaders particularly new leaders believe that they have the answers to all the problems. They do not and should not.
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Supervision: Stay or go? Continued
Alternatively, it may be possible to get what you need from more than one supervisor; for example, a technical specialist and a child specialist. Certainly, terminating the supervision relationship needs careful thought and, where possible, open discussion with the supervisor. It’s likely that how the ending is conducted will, for both parties, have echoes of other relationships that have ended. An awareness of this dynamic can hopefully ensure that past habits and patterns are not repeated and that new learning can occur. When selecting a new supervisor, consideration needs to be given to the factors that led to the termination of the previous supervisory relationship. These should be spoken about with the new supervisor. Careful attention should be paid to parallel processes in work with clients to ensure that this work does not become a vehicle for unresolved issues from supervision.
Duties and responsibilities Considering changing supervisor is a complex and somewhat vexed question. Both supervisor and supervisee bring their personal history and expectations to the process. It’s not therapy, yet we have to closely scrutinise what we do that enriches or contaminates our engagement. Supervisors have responsibilities to the clients of their supervisees, to the public (in terms of professional standards), as well as to supervisees themselves. The discharge of these responsibilities is not always palatable to us, even if we know they are necessary. To challenge the fitness of supervision, we need to educate ourselves about what is goodenough supervision and what our rights are in the process. We too have a duty to our clients, the public and ourselves, if we believe our supervisor has breached expected professional standards and behaviour. If this is the case, then we must act to seek support for ourselves and space to think through the actions that need to be taken. If, however, the rupture in supervision can be feasibly repaired, then both parties have to commit to exploring their contribution to the process and finding a way forward so as to again work effectively together.
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References 1 Casement P. On learning from the patient. London: Routledge; 1985. 2 Ellis MV, Berger L, Hanus AE et al. Inadequate and harmful clinical supervision: testing a revised framework and assessing occurrence. The Counselling Psychologist 2014; 42: 434–472.
Further reading A Manual for Evidence-based CBT Supervision (Derek Milne and Robert Reiser) CBT Supervision (Sarah Corrie and David Lane) Psychotherapy Supervision (Maria Gilbert and Kenneth Evans) Handbook of Psychotherapy Supervision (C Edward Watkins Jr (ed)) The Working Alliance: theory, practice and research (Adam Horvath and Leslie Greenberg) This article first appeared in the BACP divisional journal Children, Young People and Families, March 2019. Linda Bean MBACP (Accred) has an MA in Integrative Psychotherapy and is a BABCP Accredited CBT therapist. She works in the NHS and private practice as a psychotherapist and supervisor. She is also a committee member of the BABCP Supervision Special Interest Group. Kevin Perkins is a qualified child, adolescent and adult integrative psychotherapist. He has worked in CAMHS for over 34 years and is now working in a voluntary capacity in the charity sector as a psychotherapist with young, unaccompanied asylum seekers, refugees and victims of community violence and torture.
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To challenge the fitness of supervision, we need to educate ourselves about what is goodenough supervision and what our rights are in the process.
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Materials used to support cognitive behavioural therapy for depression: A survey of therapists’ clinical practice and views The April 2016 issue of CBT Today carried a request for therapists to help with the INTERACT study. Now, the study authors can share their findings. CBT is an effective treatment for depression and patients who learn skills in CBT seem less likely to relapse. Doing CBT ‘homework’ outside of the therapy session is associated with better outcomes. Introducing resources such as worksheets and psychoeducational materials to the patient during the therapy session may facilitate this. However, very little is known about the resources that therapists use to support one-to-one CBT for depression, or how effective therapists think these materials are. As part of the NIHR-funded INTERACT study, researchers conducted a survey to identify materials that are commonly used by CBT therapists, and that therapists think are the most effective in bringing about clinically helpful change in adults with depression. The findings have recently been published in the journal Cognitive Behaviour Therapy. In total, 818 high-intensity, BABCP-accredited therapists completed the questionnaire, making this the largest survey of BABCP therapists to date. The study found that the most frequently used materials were: symptom measures (e.g. PHQ-9), lists of problems and goals, activity schedules, behavioural activation diaries/plans, and case formulation. These frequently-used tools align with core competencies for CBT for depression. The resources viewed as the most effective were: activity schedules, behavioural activation diaries/plans, case formulation, thought records, and resources to support the identification of conditional beliefs. On the other hand, symptom measures, sleep diaries, and computerised CBT/online materials were rated as less effective. Therapists also used a wide variety of books and online materials to supplement their one-to-one work with clients with depression. Websites that provided online resources (such as client worksheets) for therapists were very frequently used;“Get Self Help”, “Centre for Clinical Interventions”, and “Psychology Tools” were the most popular.
The study authors would like to thank all the therapists who helped with this survey. A copy of the paper is available on request by contacting the INTERACT team at bris-interact@bristol.ac.uk
So, what are the clinical implications of this research? Understanding more about the materials that therapists use as an integral part of their work can inform the development of “technology-enabled” psychological services that may address the increasing demand for access to psychological treatment. Such technological innovation could potentially revolutionise mental health care, enabling treatments to be delivering in a way that increases uptake of, and adherence to, therapy. The survey results suggest that integrated or ‘blended’ systems should incorporate a range of resources from sources familiar to therapists and be designed to allow flexibility of use, with online resources accessible to patients and therapists to view and edit, both within and between the therapy sessions. This would enable therapists to tailor CBT delivered online to individual patient’s needs, as they do in face-to-face therapy. May 2019 21
Leave your fear at the door Marcia Manderson has been working with men who have experienced historical sexual abuse or have been raped for close to two years now and in that time, has gone through an array of emotions and learnt so much about how men deal with their pain. Here, she tells CBT Today readers of her experiences
22 May 2019
feature I came directly from a service that worked with women only survivors of sexual abuse to a male only service and it was an interesting transition, as at this stage I was unaware of the level of sexual violence males encounter. Like females, males can also experience sexual traumas in childhood, through to adult domestic and non-domestic relationships. Female clients overall have been very protective of me in the room, especially when it came to them talking directly about their abuse. They would frequently ask me if I would be okay after our session, and if I had someone to talk to as they didn’t want to leave me with such tough material. This is an extreme contrast to male survivors as I have not once been asked if I will be okay after sessions. It can feel as though they are literally handing you a huge bag full of dynamite and wanting you to take it far away from them and explode it. Initially I was overwhelmed by this way of being as I didn’t quite understand how men related to their emotional pain, or the release of it. It became apparent that they did not have a way of relating to their vulnerabilities that was as finely honed as us women, but they shared the same level of vulnerabilities, especially around their trauma. The fact that my clients were able to cry uncontrollably, tell me they were scared that they would take their lives, describe the fears they have that they may abuse others, discuss their confusion around their sexuality in childhood and adulthood, discuss what it means to be respected as a man in society and their felt inadequacies around their manhood is a vulnerable act. From my experience, there is an expectation that because you are doing the work that you do, you can take whatever information they impart and this may be part of the reason why some male clients feel they don't have to protect you. But for others, once trust has been established, they will soften their language and become gentler which I have come to realise is their way of protecting me. Males are statistically proven to take longer than females to disclose sexual abuse, for reasons of societal beliefs and values around what it means to be a man. Therefore, in my experience as a therapist when male clients do disclose, it can be their first disclosure in possibly 30 years and therefore, loaded with anger, anxieties, guilt, shame and confusion. I feel it is beneficial to know how perpetrators' minds work, so that you can inform your clients when they experience some of the self-blame that comes as they start to process the trauma. When we understand the perpetrators,
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Men can sometimes adopt more extreme coping mechanisms for their survival. They can include drug and alcohol misuse, violent behaviours (generally to self, but not exclusively), severe suicidal ideation, complexed mental health issues and street homelessness.
then I feel we can truly start to make changes to this area of work.
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David Finkelhor’s model of sexual offending was originally developed as a way of understanding the process or behaviour of adults who sexually offends against a child. 1. Motivation to Offend 2. Address External Inhibitions 3. Ensure Victim’s Compliance 4. Overcome Internal Inhibitions Men can sometimes adopt more extreme coping mechanisms for their survival. They can include drug and alcohol misuse, violent behaviours (generally to self, but not exclusively), severe suicidal ideation, complexed mental health issues and street homelessness. Therapists need to be open to these types of maladjusted coping strategies sometimes being linked to sexual trauma, and gently explore things further instead of looking at the behaviours as an isolated act. I am aware that when we offer therapy, we consider all presentations, however I believe that these extreme behaviours can be labelled as simply too extreme, especially in men and therefore the depth of the trauma be overlooked or missed completely. These behaviours can be seen as chaotic and threatening for the therapist and boundaries can be put in place where there is a need for exploration. I feel we can sensitively ask men questions about their coping strategies if we suspect there may be a link to sexual trauma, we already have the skills to gather sensitive information, we now need to navigate our personal fears around men and trauma of a sexual nature. Assessment seems a perfect time to ask when their coping practices were put into place, and if the client can remember any reasons or issues they were struggling with at the time. When you look at critical incidents around family relationships, including relationship with their step parents, Continued overeaf May 2019 23
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Leave your fear at the door Continued
“ grandparents and close relatives both male and female, ask your clients what they thought of those individuals who were around them as youngsters. Ask them about any problematic adult intimate relationships, and if there is any hint of sexual trauma, ask the client how/if this has impacted on his day to day life. Always acknowledge what they have disclosed, even if it is to ask them what they would like to do at that point, in terms of revisiting the issue in another session. Let your client lead via his response. If he chooses not to explore this any further, it may be enough that to know that he has trusted you. I currently represent Survivors Manchester as part of a therapy team in a category C male prison, where we not only work with sexual trauma but also common mental health issues. When I was having my induction for this role I realised how daunting it was going to be, seeing clients alone, with only a prison radio and panic button close by for reassurance and safety. My colleagues decided not to have radios in the therapy room as they felt they were intrusive, as it was not possible to use a radio without being on the general channel that reported all incidents, and this was a busy frequency. However, as a female I did not follow my male colleague’s decision, as my fears were rearing their head.“What if I get attacked and I’m too slow to shout for help”? “What if the guys test me”? “What if I can’t relax in session”?
As a female working with sexual trauma I have had to work hard not to become too desensitised and vicariously traumatise all those around me. As in my day to day work, I wouldn’t say that I am not shockable but I am aware it can take a lot to phase me. Working at Survivors Manchester has broadened my knowledge of male sexual trauma and just how prolific it can be. I feel we need to continue to Break the Silence on all sexual abuse and understand that male sexual trauma does exist. As therapists we are well placed to continue these dialogues and bring these taboo conversations into the light, whilst working with some of these self-destructive behaviours that can affect many men as a consequence of sexual abuse and rape.
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Closer to my first client session I made a U-turn and decided to ditch the radio. It felt as if the radio represented my fears rather than my ability to hold a therapeutic space and practice unconditional positive regard. If I had the radio in the room I would not have to look at what I feared, I could continue to see my clients but have one ear on myself without challenging my own prejudices. It was the best decision I have made as the therapy room reflects as a space for vulnerabilities to feel safe to take their place, I feel this is particularly important in a forensic environment where your congruent self is on show and can be closely scrutinised. 24 May 2019
As a female working with sexual trauma I have had to work hard not to become too desensitised and vicariously traumatise all those around me. As in my day to day work, I wouldn’t say that I am not shockable but I am aware it can take a lot to phase me.
Marcia Manderson is a Cognitive Behavioural Psychotherapist working for Manchester Psychological Therapies Service (Central Team) at Greater Manchester Mental Health and Survivors Manchester where she works as a Trauma Informed Therapist with men and boys who have been sexually abused or raped.
branches and special interest groups Chester, Wirral & North East Wales Branch
Manchester Branch
presents
presents
Imagery and Imagery Rescripting
Metacognitive Therapy for Rumination and Depression
with Tobyn Bell
with Dr Costas Papageorgiou 16 September Manchester
5 June Chester
To find out more about these workshops, or to register, please visit www.babcp.com/events or email workshops@babcp.com
North East & Cumbria Branch
Scotland Branch
presents
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CBT for Binge Eating with Professor Glenn Waller 27 June Newcastle
Innovative Treatment for Persistent Depression. A Primer with Jonathan Linstead and Massimo Tarsia 14 June Glasgow May 2019 25
branches and special interest groups South East Branch
West Yorkshire Branch
presents
presents
CBT for Body Dysmorphic Disorder with Anna Smith 19 September
Cognitive Behavioural Chairwork from the inside out: A self-practice/ self-reflection workshop
CBT in Pregnancy and with Parents and Carers of Infants: Holding the baby in mind with Claire Wild 14 June Leeds
with Matthew Pugh and Tobyn Bell 2 & 3 October
CBT for Social Anxiety with Dr Robert Medcalf 21 November All events are in Sevenoaks To find out more about these workshops, or to register, please visit www.babcp.com/events or email workshops@babcp.com
Devon & Cornwall Branch
Liverpool Branch
presents
presents
Adapting CBT for Autistic Spectrum Disorders
Applying ACT to ourselves:
with Darren Liddle 18 October Buckfast
26 May 2019
A self-practice and self-reflection workshop with Jason Roscoe 31 July Liverpool
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The MyWellbeing College is recruiting two exciting full-time opportunities for our forward-thinking IAPT service High Intensity CBT Therapist/Supervisor Based in the Airedale, Wharfedale and Craven team
EMDR Consultant Based in the South Bradford team
To find out more, visit bdct.nhs.uk/current-vacancies
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30 May 2019
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32 May 2019