Psychological strategies

Cognitive behaviour
Maarit Harden therapy
Incorporating therapy into general practice

Background I have always enjoyed listening to patients’ stories and often

Cognitive behaviour therapy is a talking therapy that looks struggled to keep to time. I could see that unless I changed my
at the connections between our emotions, thoughts and practice I would lose some patients and possibly gain those who
behaviours within the context of specific circumstances and other general practitioners felt talked too much. It was in this
symptoms. context that I decided to learn a skill that would enable me to
Objective see these patients with a more structured approach. I decided
This article describes cognitive behaviour therapy, its to learn cognitive behaviour therapy (CBT), especially to help
evidence base and applications. Pathways for further training my chronic somatising patient population who had come to see
for general practitioners in cognitive behaviour therapy are me because I listened. This group will be familiar to many GPs.
described. Cognitive behaviour therapy enabled me to provide a structure
Discussion to my discussions with anxious somatising patients who would
Cognitive behaviour therapy is an effective treatment for otherwise keep ‘rambling’ about their symptoms. The first
mild to moderate depression, generalised anxiety disorder, courses I attended were very general and really did not impart
panic disorder with or without agoraphobia, social phobia, many useful specific skills for use in the consulting room. Then
post-traumatic stress disorder, and childhood depressive I chanced upon a CBT treatment manual for anxiety disorders
and anxiety disorders. At its simplest, it can take the form written by Gavin Andrews et al1 (see Resources). This textbook
of an exercise prescription, teaching relaxation techniques, clearly delineated how to identify specific anxiety disorders and
assistance with sleep hygiene, scheduling pleasurable
provided sample treatment manuals that could be photocopied
activities and guiding the patient through thought
for patients.
identification and challenge. With some basic training in the
area, GPs are well placed to provide basic cognitive behaviour
therapy treatments, particularly to patients at the mild end The first case I treated with my newly acquired skills was an anxious chronic
of the spectrum of mental health disease, as they already somatising patient who would typically take more than 45 minutes whenever
know their patients well and have a therapeutic alliance with she attended (Case study 1). Her main symptom was chronic fatigue. To
them. In some cases, this may be all that is needed; however, my surprise, she made steady improvements with CBT and began to be
patients who have more complicated issues or more severe involved in life again – taking up tai chi, quilting and holidays, which she had
symptoms may require specialist psychiatrist or psychologist previously not felt she could do. This came from simple activity scheduling
referral. and experiments with brief periods of exercise to see when her fatigue
Keywords occurred. I decided to try it with other patients, with mixed success. Some
cognitive therapy; psychotherapy would agree to attend for 30 minute weekly appointments but would not
do the homework tasks. Some got stuck on cognitive restructuring; others
had complex issues such as addictions and personality issues, which didn’t
lend themselves to a structured program. However, while my initial success
encouraged me to keep going, I began to wonder if there was a deficiency
in my CBT technique when patients did not continue. I did a supervised
clinical attachment under a psychiatrist, which involved attending a 4 week
CBT day program at a private hospital. During this attachment, I discovered
that my CBT skills were not deficient but that there may be multiple reasons
why a patient might not return for follow up. This includes the fact that
some patients only need limited CBT skills to enable them to master an
issue causing distress (Case study 2), discomfort with the requirements

668 Reprinted From Australian Family Physician Vol. 41, No. 9, september 2012
of CBT, or with pursuing these matters with a GP. Lack of engagement see me (her GP) instead. There was no evidence of clinical
could also reflect an ongoing pattern of avoidance, regardless of the depression. Rose did not think she was overly anxious but she
treatment options presented to them. The cases I have seen over the did identify that she was under stress. Her symptoms began
years who have done well are patients with anxiety disorders and mild when her boss indicated that he wanted to sell the shop she
had been working in for the past 10 years. She had never
to moderate depression (Case study 1 and 2). There is a great sense
thought she could be a business owner but her partner had
of personal achievement when patients get better as a consequence
encouraged her to apply for a business loan. Her symptoms
of the collaboration that occurs within a good therapeutic alliance and
coincided with the application being accepted and the start of
their willingness to do their part in the treatment process. I have also her owning the shop. She felt the stress of financial insecurity
benefited from the application of CBT principles to my own life and I that comes from stepping into a role she had not previously
believe my anxious children have benefited from this life skill. attempted. She did not qualify for a mental health plan as she
did not fulfil the criteria for a mental health disorder. Mental
Case study 1 health item numbers were not used for her visits.
My name is Jane.* I am lucky because I got seriously sick
when I was relatively young, in my 40s. I say that I am Rose attended twice. We discussed the physiological responses
lucky because at that time there were some good people to to stress (via the adrenaline story) and I gave her some simple
help me. But especially because it meant that I learnt some breathing and progressive muscle relaxation techniques. I used
valuable lessons, which have been very helpful since. a simple thought challenging activity to address her concerns
about running the business. After the second session, Rose did
The most valuable lesson that I learnt was that I can help not attend again for some years. I chanced to walk into her shop
myself. Not only to help myself by going to ask good people one day – she recognised me and told me what a difference
for help. Not only to help myself by taking the proper the CBT made to her being able to take on the business. She
medicine as instructed and changing my eating habits. thanked me profusely.
But also knowing that I can help myself feel physically
and emotionally better by thinking in a different way. By *Not her real name.
changing the way I look at my actions and my feelings and Case study reproduced with permission from the patient.
my thoughts (changing my perception). By using thinking
skills to help me deal with my emotions and to start new, Background
helpful thinking habits. Once I understood the processes Since ancient times, philosophers have pondered the connections between
and could change my thinking I could ‘break vicious cycles’ reasoning and actions, emotions and symptoms. Cognitive behaviour therapy
of stress, pain, physical and emotional symptoms and help is a talking therapy that looks at the connections between our emotions,
myself feel better.
thoughts and behaviours within the context of specific circumstances
That is how I was able to improve from several conditions, and symptoms. A meta-analysis by Butler et al2 in 2006 showed that CBT
but especially from chronic fatigue and anxiety. To help with was an effective treatment in mild to moderate depression, generalised
this retraining of my thought processes I found that I greatly anxiety disorder, panic disorder with or without agoraphobia, social phobia,
benefited from a doctor who was trained not only in the
post-traumatic stress disorder, and childhood depressive and anxiety
medical aspect of treating disease but who also understood
disorders.1 Some benefit was also seen in patients with marital distress,
the interplay between the mind, the emotions and the
anger, childhood somatic disorders and chronic pain.1 This skill set also has
physical body, who treated my whole being, not just isolated
parts of me. It also required the doctor to give me time to the potential for wider applications in the setting of acceptance of chronic
think aloud so that we could problem solve together, so that illness, compliance with medication, stress management, insomnia, weight
I could gain confidence and techniques so that I could do control issues and many other nonmental health scenarios.2 While this
similar problem solving on my own. This has been most therapy takes time (which may be limited in the general practice setting),
useful to me. it tends to be shorter than other psychological techniques as it is highly
* Not her real name. structured. With some basic training in the area, GPs are well placed to
provide basic CBT treatments, particularly to patients at the mild end of the
Case study reproduced with permission from the patient.
spectrum of mental health disease as they already know their patients well
and have a therapeutic alliance with them.3 In some cases, this may be all
Case study 2
that is needed; however, patients who have more complicated issues or
Rose,* 52 years of age, attended because she was feeling
more severe symptoms may require specialist psychiatrist or psychologist
breathless. She had attended a number of other GPs and
had extensive tests for asthma and heart conditions, and referral. Cognitive behaviour therapy can still be beneficial to these patients,
also attended a thoracic physician, who had confirmed that particularly if there is a long wait for the upcoming appointment. Cognitive
she didn’t have asthma or a heart condition. The specialist behaviour therapy strategies may also be helpful for patients who have been
suggested that she might like to see a psychiatrist. This started on antidepressants to impart strategies to cope while waiting for the
didn’t sit well with her and she made an appointment to onset of the antidepressant effect. Cognitive behaviour skills can assist GPs

Reprinted From Australian Family Physician Vol. 41, No. 9, september 2012 669
 FOCUS Cognitive behaviour therapy – incorporating therapy into general practice

with their own life issues. They provide a framework for dealing with stressful
Table 2. Factors associated with success
life events, a way to work through emotional trials, problem solving with work
for cognitive behaviour therapy5
stressors and valuable information for dealing with anxious children or family
members and making lifestyle changes. Patient factors
• Can the patient recognise and talk about their
What is cognitive behavioural therapy? thoughts?
Cognitive behaviour therapy is a very structured form of talking therapy with • Is there an awareness of emotions and ability to
label feelings and understand the link between
specific time limits, structured activities and homework tasks. It involves
feelings, thoughts and behaviours?
working with patients to challenge and change unhelpful ways of thinking that
• Does the patient accept a personal responsibility
lead to negative emotions and hence psychological or other symptoms and to to change?
change habitual and unhelpful behaviours that may be associated with these
• Can the patient explore their anxiety or is there a
emotions.4 In its simplest form it can take the form of an exercise prescription, high level of avoidance?
teaching relaxation techniques (Table 1), assistance with sleep hygiene, • Is the patient able to develop trust in the process
scheduling pleasurable activities and guiding the patient through thought and develop a therapeutic alliance?
identification and challenge. Factors which influence success with treatment • Is there a previous positive experience of therapy
are shown (Table 2). or a general optimism and willingness to give
The initial consultation involves information gathering and exploration therapy a go?
of the patient’s story. The patient is given an explanation of CBT and how it • Is there a capacity to remain focused and work
works. Expectations of therapy are discussed and a plan made for the following on issues in depth?
sessions. There is negotiation of how often the sessions will occur and how Therapist factors
long the therapy is planned for. It is not open ended and should have a defined • Engagement with the patient by active listening
endpoint. Often handouts are given to reinforce the session. Each session also • Development of a formulation and plan that the
has a homework task: for example, a brief breathing exercise if the patient is patient agrees with
anxious, or a discussion about a routine task that has been neglected if the • Equal collaboration – therapist provides skills
patient has depression. and structure, patient provides setting and
history
Importantly, CBT doesn’t involve the doctor ‘doing therapy’ on the patient,
• Nonjudgemental and focused on ‘here and now’
rather the doctor acts as a coach to help the patient make their own lifestyle
changes. Allowing patients to take responsibility for themselves, make good • Expectation of good outcome/optimism about
therapy
choices and problem solve the issues that arise is empowering and has the
External factors
potential to improve outcomes. It is helpful to collect patient stories to describe
to other patients considering working with CBT. This can engender hope and • Therapy is affordable in terms of money and time
confidence that this is a worthwhile skill to learn and that their condition is not • Support from friends and family to persevere
with tasks and changes
dissimilar from others who have experienced CBT and have improved.

Table 1. Simple relaxation strategies

Teaching relaxation skills to patients is a worthwhile activity as it targets physical symptoms of tension, gives the patient
mastery over their body, and is a positive activity for depressed patients as well as being a distraction technique for
anxious patients and a way to reduce the symptoms of hyperventilation. An example of a simple relaxation strategy is:
• Find a safe, quiet place to sit where you will be comfortable
• Plant your feet firmly on the ground and push down to feel the solidity of the ground or floor
• Gently clasp your hands together across your lower abdomen below your belly button
• Notice your breathing – notice the pace, the depth and how your muscles are working automatically
• When you are ready, take a slow deep breath over about 5 seconds. Hold the breath for a few seconds
•  Breathe out again, slowly noticing your hands over your abdomen rise and fall with the breath – again taking about 5
or more seconds to let the breath escape
•  Breathe in slowly again, but this time clasp your hands together tightly while you breathe in – making sure that you
don’t cause pain with the clasping
• As you breathe out slowly over the next 5 seconds, relax your hands and arms fully
•  Repeat the slow breathing, going in over 5 seconds and out over 5 seconds, but now tighten other muscle groups
where you feel tension as you inhale and then relax the muscles when you breathe out. Repeat this exercise three or
four times, focusing on any areas of tension in your body
This technique can be utilised as a start of a mindfulness meditation exercise

670 Reprinted From Australian Family Physician Vol. 41, No. 9, september 2012
 Cognitive behaviour therapy – incorporating therapy into general practice FOCUS

Training in CBT Summary

The federal government has encouraged GPs to be more involved Cognitive behaviour therapy is a valuable resource for time poor doctors as
with treating their mental health patients with focused psychological it provides a structure for mental health consultations so that GPs can use
strategies (FPS) and provides higher rebates for GPs who are trained their time more efficiently. General practitioners with an interest in mental
in these skills. There are training programs accredited by the General health disorders are encouraged to become familiar with this technique by
Practice Mental Health Standards Collaboration (GPMHSC) in most researching it further and locating a suitable training program to familiarise
states. These can be located through the RACGP website, privately themselves with the skills and strategies. They can then start to implement
run training programs and mental health networks (see Resources). this in their practice settings and may even be pleasantly surprised by the
The GPMHSC website also has application forms for doctors who outcomes, as I was with my very first patient.
wish to submit prior training. However, the GPMHSC will not accept
training that is more than 3 years old and favours training that is Resources
specific to general practice. • GPMHSC: www.racgp.org.au/gpmhsc
• Information from the RACGP/GPMHSC about training opportunities in
FPS: www.racgp.org.au/gpmhsc/findtraining
Medicare item numbers • Australian Government Department of Health and Ageing. MBS Online
Medicare outlines specific activities that qualify as FPS under the notes on focused psychological strategies for item numbers 2721–2727:
explanatory notes for the FPS item numbers (Table 3). In practice, if www9.health.gov.au//mbs/fullDisplay.cfm?type=note&q=A47&qt=noteI
the GP wants to use the specific item numbers, the patient needs to D&criteria=2721
• Mental Health Professionals Network: www.mhpn.org.au.
have a mental health plan whether they are being referred elsewhere
or having CBT provided by the GP. Thus, to claim the items, the patient Author
needs to have a mental health disorder. While CBT is useful for Maarit Harden MBBS, FRACGP, is a general practitioner, Brisbane,
patients without a mental health disorder (Case study 2), GPs cannot Queensland. [email protected].
use the FPS item numbers for these patients. General practitioners Conflict of interest: The author facilitates the CBT for GPs Training Program.
can access other time based attendance item numbers, which makes
References
CBT a useful skill as these patients would only be able to access 1. Andrews G, Creamer M, Crino R, Hunt C, Lampe L, Page A. The treatment
allied health practitioners privately. If you become skilled at CBT then of anxiety disorders – clinician guides and patient manuals, second edition.
it becomes part of your practice and becomes applicable across the Cambridge: Cambridge University Press, 2003.
2. Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-
patient spectrum. behavioral therapy: a review of meta-analyses. Clin Psych Rev 2006;26:17–31.
3. Heatley C, Ricketts T, Forrest J. Training general practitioners in cognitive
behavioural therapy for panic disorder: randomized-controlled trial. J Ment
Table 3. Specific activities that qualify as Health 2005;14:73–82.
focused psychological strategies under 4. David L, Freeman G. Improving consultation skills using cognitive-behavioural
Medicare (items 2721–2727) therapy: a new ‘cognitive-behavioural model’ for general practice. Educ Prim
Care 2006;17:443–53.
• Psycho-education (including motivational interviewing) 5. Saffran J, Segal Z, Vallis TM, Shaw BF, Samstag LW. Assessing patient suit-
• Cognitive behaviour therapy including: ability for short-term cognitive therapy with an interpersonal focus. Cognit
– behavioural interventions Ther Res 1993;17:23–38.

– behaviour modification
– exposure techniques
– activity scheduling
– cognitive interventions
– cognitive therapy
• Relaxation strategies
– progressive muscle relaxation
– controlled breathing
• Skills training
– problem solving skills and training
– anger management
– social skills training
– communication training
– stress management
– parent management training
• Interpersonal therapy
Source www.racgp.org.au/gpmhsc/fps

Reprinted From Australian Family Physician Vol. 41, No. 9, september 2012 671