Hey guys, so welcome to my next post on approaches. Just like the last approach, try to only use this as a foundation- starter for reading other bits of information to find out more interventions or practices of work and feel free to let me know how else you’d see the cognitive behavioural approach in practice/journal articles.
Okay so, the cognitive behavioural approach. I studied psychology before occupational therapy and I felt like this approach would be a breeze but understanding the concepts and applying it can look quite tricky in practice. We aren’t CBT therapist and with this approach sometimes its hard to see it’s occupational focus, even when it is applied- but more of this later.
Also, just to note there is also a cognitive approach and a behavioural approach which are two separate things. The literature on these individually are few and far between but I have wrote approach posts on these so hopefully I can shed a little bit of light on these to help break them up so check these out when I finally post them. But for now let’s focus on… The world famous fusion that is cognitive behavioural.
But first, what is an approach? (if you’ve read any of my other posts on approaches this is just a classic cntrl c and v situ- so skip this)
An approach can be seen as a way of looking at one’s own individual practice while using multiple professional models and is considered to be a structured theory which can be applied within practice (McClean 1974; Seymore and Boniface 2012). Itcan often be used in many different ways but should be used specifically to the profession’s philosophy. So what this means is when used by an occupational therapist, it should reflect the occupational therapy philosophy. If it does not reflect the professional’s philosophy there is a danger that it will increase blurred lines within roles, which is already an issue within occupational therapy. Therapist need to have a good knowledge of the approach giving good clinical justification and fit with the patient’s needs and strengths in order for it to be effective. Although in practice occupational therapists apply a variety of approaches, generally there is always a primary approach that is joined by others.
History of the cognitive behavioural approach
In the beginning the cognitive and behavioural approaches were separate (check out my other approaches section in order to see them individually (COMING SOON if you’re reading this pre posting)).The fusion fest then happened when it was discovered that the cognitive was too cognitive, due to its failings of not looking at the behaviours that developed from individuals cognition. Beck then discovered that both approaches focuses on present problems and quite naturally emphasise how our thinking can influence our actions. From this Beck formed CBT which links emotions, motivations and behaviour together. Challenging maladaptive outcomes. Very quickly they found that cognition and having an understanding of abnormal behaviours had a positive clinical impact.
The approach focuses on automatic learned responses and challenges a person’s interpretation of events, not the event themselves. It is believed that distorted or irrational thinking patterns can lead to emotional problems and maladaptive behaviour. It breaks down aspects such as generalisation, labelling and selective abstraction to highlight how their thoughts are unhelpful and influence their negative behaviours. So the CBT approach focusses on addressing cognitive processes to change behaviour, promoting positive outcomes.
For example; a person with anxiety might not want to go outside for fear of catching coronavirus. So time would be spent to discuss the reasons behind that anxiety, their automatic thoughts and behaviours breaking it down in order to reduce anxiety such as If I go out I’m going to die, everyone had coronavirus. This then means the behaviour shown is not leaving the house, obsessive cleaning etc. By staying inside this is however reinforcing your automatic thoughts. This is a very generic example and I have really simplified it but I’m just trying to illustrate automatic thoughts and behaviours.
OT interventions
Some argue that CBT really blurs lines with psychologists and occupational therapists. However the argument that CBT can be used to help address clients attitudes toward their conditions especially when these attitudes have a negative impact on occupational engagement (Strong 1998). When utilising the cognitive behavioural approach therapist take the perspective that therapeutic intervention can alter dysfunctional modes of thinking which in turn has a behavioural response (Dobson & Dozois 2010).
Taylor (1988) tried to make it clear in how using CB approach would look in occupational therapy. Taylor said that a person must be adaptive while taking part in everyday life. If something like anger interferes with their ability to be adaptive then it is the occupational therapists job to manage that anger. Discussing behaviours, to understanding the cognitive reasoning which interferes with their functioning can help correct cognitive distortions. This can help the individual, where they can take responsibility for their behaviour and aim to change how they think about themselves. These can be completed through food diaries, relaxation training, coping skills and completing journals. By doing this, this is creating a activity approach to restructuring their thinking and behaviour. Other methods used within the cognitive behavioural approach are.
Anxiety management which can involve a graded approach in regards to the service users individual anxieties. Again, an individuals interests would need to be assessed but this had been done in recent literature through using activities such as yoga (Khalsa et al. 2015). Yoga, which focuses on breathing, is proven to have numerous physical and psychological benefits. Computer therapy (Newby et al 2016) and meditation, allowing individuals to focus on the here and now.
Problem solving which can be done alone with the therapist or within a group. In order to understand why their behaviours or thoughts hinder their occupational participation.
In regards phobias systematic desensitisation is similarly used within occupational therapy. Again, this is another graded approach to get them to change their behaviour by controlling their thoughts. For example if someone is afraid to get the bus. First it might be walking to the front of their house, then to the end of the street, then to the bus stop, then getting on a bus and straight off, taking one stop. At each stage the service user needs to relax before being able to move onto the next one.
Critique
Strong evidence based for anxiety and depression. Supported by NICE.
Blurring of lines as it is quite complicated within practice. The behaviour aspects are highly occupationally focuses however it could be argued that understanding their cognition is not a role of an occupational therapist. However, interventions with occupational therapy have shown to be highly beneficial and well accepted. Its therefore important to make sure the exploration of cognition are considered in favour of occupations. Focusing on the occupation first, rather than underlying issues.
Philosophy and Compatibility
The approach itself is highly patient centred as it focuses on functional problem solving, understanding their individual thoughts and behaviours. Chooses activities in order to explore their cognition, which in turn can change their behaviour. Modify’s through mutual understanding It has holistical idealogy as it’s believed if he change their thoughts we change their behaviours which can allow their promote occupational independence in a variety of models. Such as motivations and performance capacity in the MOHO and engagement part of the CMOP-E. Although need to be aware if there are physical inhibitors present they must also be addressed. Similar to occupational practice which looks at the here and now. What are the current barriers and how can we move past them.
Fits with occupational therapy models.
Strengths and weaknesses
Spelky et al, (2015) in their research highlighted how cognitive behavioural approaces on intervention increased the employability of individuals with disabilities. which in turn helped them to provide a more holistic approach to their patients.
Provides more evidence based intervention as occupational therapy is trying to incorporate a more theoretical background through the use of occupational science.
Patients must be motivated otherwise evidence has shown it will not work.
Top down approach- focus on function first.
Multidisciplinary Uses
As I have previously mentioned, clear active plans are needed to be created in order to show how to the cog behavioural approach will be used occupationally, so don’t infringe on other services. CB itself is widely used across a number of intervention services. CB therapy (or CBT) traditionally in a one hour psychotherapy session. Knowledge of it has been spread to healthcare professionals to support carers as well as patients. Interventions are now online, which are also supported by the NICE guidelines to emphasis the need for patient engagement highlighting the real validity in it as an approach as so widely used.
Bibliography
Khalsa, M.K., Greiner‐Ferris, J.M., Hofmann, S.G. and Khalsa, S.B.S., 2015. Yoga‐enhanced cognitive behavioural therapy (Y‐CBT) for anxiety management: a pilot study. Clinical psychology & psychotherapy, 22(4), pp.364-371.
As always Duncan. 2011. Foundations of occupational therapy
Boniface and Seymour 2012. Using occupational therapy theory in practice.
