Cognitive behavioural therapy (CBT) is an effective treatment for depression and patients who learn skills in CBT seem less likely to relapse. Between-session tasks (‘homework’), where patients practise skills learnt during sessions with their therapist are an integral part of therapy. Doing 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, we know very little about the resources that therapists use, both between and within sessions, to support one-to-one CBT for depression, or how effective therapists think these materials are.
Our aim in this study (recently published in Cognitive Behaviour Therapy) was to identify materials that are commonly used by CBT therapists, and to identify the materials therapists think are the most effective in bringing about clinically helpful change in clients with depression.
A total of 3665 therapists accredited by the British Association for Behavioural and Cognitive Psychotherapies (BABCP) were invited to take part in the survey. The survey was also promoted via contact with Improving Access to Psychological Therapy (IAPT) service leads working within the National Health Service (NHS) in the UK; and through the BABCP.
The questionnaire asked therapists about the materials they used to supplement one-to-one CBT for depression, focusing on tools recommended in CBT for depression treatment manuals or that would support key CBT techniques. These included: symptom measures; written agendas; activity schedules; behavioural activation diaries; written resources to support behavioural experiments; mood diary; thought records; resources to support identification of unhelpful thinking; case formulation; relaxation materials; sleep diary; computerised CBT and online materials; and books/workbooks.
Therapists were asked to indicate how often they used these materials, and whether the materials were given to clients for use between, or during, the CBT sessions. Therapists also listed any books, computerised CBT, online or other materials they used to supplement one-to-one work with their last three clients with depression. Finally, therapists were asked about their wider experience of using materials to support one-to-one CBT for depression, and to indicate how effective each of the listed materials were in bringing about clinically helpful change.
A total of 818 high-intensity, BABCP accredited therapists, from a variety of professional backgrounds completed the questionnaire, making this the largest survey of BABCP-accredited therapists to date. We found that the most frequently used materials were: symptom measures, providing lists of problems and goals, activity schedules, behavioural activation diary/plan; and case formulation. These frequently-used tools align with core competencies for CBT for depression (https://www.ucl.ac.uk/pals/research/clinical-educational-and-health-psychology/research-groups/core/competence-frameworks-2).
All the resources were considered at least moderately effective, but some were rated more highly than others. The resources viewed as the most effective were: activity schedules, behavioural activation diary/plan, 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 by therapists.
We also found that therapists 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 cited, with the “Get Self Help” (https://www.getselfhelp.co.uk), “Centre for Clinical Interventions” (http://www.cci.health.wa.gov.au), and “Psychology Tools” (https://psychologytools.com) websites being the most popular.
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 will enable therapists to tailor CBT delivered online to individual patient’s needs, as they do in face-to-face therapy. Future work to develop novel approaches to delivering CBT may enable us to improve patient outcomes for the large number of patients with depression.
Read the full paper: Tallon, D., McClay, C. A., Kessler, D., Lewis, G., Peters, T. J., Shafran, R., Williams, C., & Wiles, N. (in press). Materials used to support cognitive behavioural therapy for depression: A survey of therapists’ clinical practice and views. Cognitive Behaviour Therapy. doi: 10.1080/16506073.2018.1541927
Photo by: March Verch