History of Cognitive Behavioral Therapy
In the early 1960s, psychoanalyst Professor Aaron Beck developed cognitive therapy after studying psychoanalytic concepts of depression. In his research, he found that people with depression spontaneously experience unconscious negative thoughts. These negative thoughts fall into three categories Category: Negative thoughts about your world and future. After spending time with these patients, Baker realized that these automatic negative thoughts were highly correlated with the individual’s emotions. Baker began to notice the rapid progress of these men After helping them identify assess and cope with their maladaptive thinking and behavior patterns. To understand the effects of this form of cognitive therapy, a randomized controlled study was conducted to see the effects of cognitive therapy on people with depression. The results show Cognitive therapy was as effective as the antidepressant imipramine. These findings are a huge milestone, as talk therapy has been likened to drug therapy. Today, CBT has been scientifically proven effective in numerous clinical trials for a variety of diseases .
What is CBT?
CBT is derived from a cognitive model of psychopathology. This theory looks at how individuals’ perceptions and thoughts about situations affect their emotional behavior and physiological responses . For example, when individuals are stressed, their minds tend to distort, Dysfunctional. If individuals learn to recognize and correct these thoughts, their stress levels tend to decrease, leading to more functional behavior. CBT teaches individuals to face their irrational thoughts in a more realistic and adaptive way so that they can their emotional state and behaviour. CBT can include many cognitive and behavioral techniques, including self-direction and adaptive coping strategies . CBT involves six overlapping sessions that can be adapted to different people with various disorders. These stages represent Different theoretical components of multidimensional therapy. Even though CBT follows a logical sequence, treatment should be flexible and individualized according to the patient’s needs.
The Six Phases of CBT
Phase 1: Assessment
Figure 1: 6 Phases of CBT
- This phase involves assessing information provided by patients and families through a series of self-reported measures and observational procedures to determine the extent of psychosocial impairment.
- The information provided determines the most appropriate course of action.
- Establish baseline measures.
Phase 2: Reconceptualisation
- Cognitive part of CBT
- Patients are usually asked to keep a self-report diary.
- Seek to help patients challenge and question their maladaptive thoughts (eg, “I am a failure in life because I am miserable”).
- Set goals together with the patient.
Phase 3: Skill Acquisition and Reinforcement
- Therapists use a variety of cognitive and behavioral strategies to teach patients how to deal with obstacles in everyday life.
- Collaboratively focused on problem-solving strategies, i.e. relaxation techniques/pacing/graded exposure/coping strategies.
Phase Four: Skill Consolidation and Application
- Give patients homework to help reinforce the skills they have learned.
Phase 5: Generalisation and Maintenance
- Patients review taught homework and practice skills and consider potentially problematic situations that may arise.
- Patients assess their progress and attribute success to their own coping efforts.
Phase 6: Post-Treatment and Follow-Up
- All aspects of therapy are reviewed.
- The therapist monitors and evaluates the patient’s use of CBT in their lives.
How and why does CBT fit into physical therapy practice?
Current physical therapy education is derived from the International Classification of Functioning and Health (ICF) model . Incorporating CBT into physical therapy practice will enhance the delivery of biopsychosocial models, providing a more holistic approach to patient-centered care. This will ensure a more comprehensive and successful journey for both patient and practitioner. Proper implementation of CBT by physical therapists within their practice will improve the success rate of treatment and overall patient outcomes.
As shown in Table 1, the fundamentals of CBT and physical therapy are comparable and tightly coupled.
Table 1: Correlative principles between CBT and physical therapy Cognitive Behavioral Therapy and patients Patient-centered care aims to identify and change behavior Correct bad habits and discover why bad habits occur in the first place Aims to build CBT skills to prevent relapse Emphasis is on self-management
Adding CBT to a physical therapist’s skill set can help patients identify and change negative thought patterns that prevent successful recovery. This enables the patient to regain an internal point of control, thereby Specific issues . Physiotherapists are in a prime position to help manage and change patients’ maladaptive thoughts. The beginning of a physical therapy evaluation begins with a subjective examination. This provides an opportunity for the physical therapist to assess whether CBT is appropriate patient tools. Appropriate tools to identify psychosocial risk factors (i.e., yellow flags) will enable physical therapists and patients to collaborate in addressing these patient issues when setting SMART goals . The treatment plan can then be seamlessly adjusted according to the body and condition Consider psychosocial conditions. This may also help reduce the impact of any negative stigma patients may have in requesting and receiving psychological support.
In some cases, a physical therapist will be the first healthcare contact for many patients. This puts physical therapists in a prime position to help treat patients holistically. In scenarios involving complex patients with psychosocial problems, the root cause of the problem is the purpose of listing Therapy can be directed appropriately through collaboration between the physical therapist and patient. This may reduce relapse rates due to previous maladaptive behaviors and reduce readmission rates.
Incorporating CBT into the current physical therapy curriculum will equip physical therapy students with the skills to early identify and manage patients who indicate yellow flags, thereby reducing the need for referrals to clinical psychologists. The Ultimate Physiotherapist Addresses Delicate Issues Psychosocial issues at the outset may reduce contact time between multidisciplinary teams and lower healthcare costs. This will have the potential to improve treatment success and reduce readmissions, as patients will learn to self-manage their behaviour.
The Missing Link in Current Physical Therapy Training
In addition to the principle of seamless integration of physical therapy and CBT, there are several gaps in current physical therapy training. 
The current curriculum:
- Emphasize anatomical neuromusculoskeletal biomechanics biomedical knowledge over biopsychosocial models
- Treating disease and injury
- Outcome measures focused on functional balance in strength movement patterns
- Offer limited interprofessional education
- Provide some education in the biopsychosocial areas of physical therapy management
- Lack of depth and focus on how psychosocial factors are assessed and managed
- More time spent on biomedical assessments and treatment of medical conditions
- Sometimes educates about models that lack an evidence base and foundation
- Lack of application and practice to adequately reinforce psychosocial principles
- Social Psychology Education is Difficult to Consolidate in Practice
In addition, Continuing Professional Development (CPD) focuses on continuing to implement biomedical models of assessment and treatment and addresses psychosocial approaches through minimal CPD workshops. CBT modules in physiotherapy courses can help further develop physiotherapy Students become more well-rounded and competent clinicians.
Current Literature to Support CBT
There is empirical evidence that CBT is effective in improving conditions such as anxiety, depression, post-traumatic stress disorder, eating disorders, and chronic pain. In the UK, the National Institute for Health and Clinical Excellence (NICE) recommends CBT as a treatment Select some of the mental health disorders mentioned earlier. In addition, there is growing evidence that the effectiveness of CBT for physical therapy can significantly improve functional pain in patients with back pain  chronic pain  and fibromyalgia  experience and coping strategies.
Table 2: Cases where CBT has been shown to be beneficialPsychiatric illnessMedical problemsPsychological problemsDepressionAnxietyPersonality disordersPanic disorder Illness Migraine Tinnitus Cancer Pain Irritable Bowel Syndrome Chronic Fatigue Syndrome Rheumatism Pain Insomnia Obesity Hypertension Couple Problems Family Problems Complicated Sadness Anger and Hostility Pathological Gambling
Evidence For The Use of CBT
There is an increased need for interventions that can prevent the development of persistent pain problems. In 1997, 10 primary care setting-based trials of early intervention for acute back pain were reviewed. These programs deal with fear and anxiety Often associated with acute pain, leading to positive outcomes under various control conditions . A 1998 study also found that a cognitive-behavioral program for patients with acute back pain significantly reduced worry and disability at follow-up visits—thus having a preventive effect measures may be feasible.
A randomized controlled trial was published in 2001 to investigate the preventive effect of a CBT group intervention in people reporting neck or back pain . Participants experienced four or more episodes of relatively severe spinal pain in the past year, but no No work for more than 30 days. Therefore, the aim is to prevent the non-patient population from developing a more severe pain problem and entering a chronic phase. The experimental group participated in a structured six-session program in which individuals met once a week in groups of 6-10 two hours. The CBT group showed more consistent improvements and fewer sick days than the control group. The CBT group also reported a decrease in fear of avoidance and an increase in the number of pain-free days, suggesting that early preventive measures may help.
Regarding absenteeism, musculoskeletal disorders (MSDs) are among the most commonly reported work-related illnesses. There is now general consensus among various occupational health guidelines for the management of MSDs. This includes identifying psychosocial disorders Recovery Provides advice that MSD is a self-limited disease and that retention at work or early return to work (RTW) should be encouraged and supported . In 2006, a large British pharmaceutical company conducted a study. Occupational Health Nurses (OHNs) are trained to Provides an intervention for workers absent from work due to various MSDs, including low back pain (LBP) and upper extremity impairment . The training package includes education about pain and pain mechanisms, can address negative beliefs and attitudes, and emphasizes the importance of staying active and healthy. Early RTWs. The results showed a reduction in the number of absent days at one particular site compared to a control site where OHN saw workers on RTW. In conclusion, this study adds to new evidence that absenteeism can also be reduced by providing information and support to employees.
CBT has also been used successfully in patients with angina . The Heart Manual is a six-week cognitive-behavioral rehabilitation tool designed to correct misconceptions about the causes of myocardial infarction (MI). In addition, it helps patients develop strategies to cope with stress so that Eliminate persistent misunderstandings. The heart manual is a way of providing educational and psychological support to post-MI patients, although it does not meet the needs of the minority who need additional help . A pilot randomized controlled trial evaluating heart manuals finds Those who received the manual had improved mood status, fewer GP contacts and readmissions six months after MI. A subsequent study found that 77 treated patients had significantly lower readmission rates and improved mood status and sense of control at 6 months .
As mentioned earlier, CBT can also play a role in treating a variety of mental health conditions. A study was published in 2002 to test the effectiveness of additional CBT in accelerating remission of acute psychotic symptoms in early schizophrenia . 5-week CBT program plus Usual care was compared with supportive counseling plus usual care and usual care alone in a multicenter trial that randomized 315 DSM-IV patients with first (83%) or second acute admission Patients with schizophrenia and related disorders. Linear regression over 70 days showing predicted trends Achieve faster improvement in CBT groups. It was concluded that CBT showed transient advantages over usual care or supportive counseling alone in accelerating resolution of acute symptoms in early schizophrenia.
Is CBT suitable for all patient groups?
As previously stated, CBT is applicable to a wide range of situations and goes beyond the initial problem for which a patient may seek treatment. Although it has been specialized and applied to a variety of specific disorders, from depression to psychosis, CBT has also become a Increasingly popular in various chronic pain conditions, especially chronic LBP . Nonetheless, there remains a subset of patients who are less likely to respond to CBT as treatment . In addition, several studies have shown that CBT methods are equally effective in reducing Pain level as a traditional intervention . Perhaps a more systematic approach of matching CBT to certain groups of patients and filtering it to those who are more likely to respond positively to treatment is what CBT needs.
Figure 2: STarT Tool Scoring System
The Keele STarT Backside Screening Tool (SBST) is designed to resolve mismatches. A sample musculoskeletal (MSK) screening tool can be downloaded here. The SBST divided LBP patients into three subgroups based on their prognosis (low risk of chronic disease, moderate risk with physical disabilities recovery and high risk of psychological impairment to recovery) . The practice of physical therapy revolves around patient-centered care. The physical therapist’s choice to use CBT as an intervention stemmed from prior CBT training and the therapist’s intuitive/clinical reasoning. another tool For example SBST can determine if there are any differences between patients. The SBST is valid and repeatable and consists of 9 items including: referred pain, comorbidities, disability, distress, catastrophe, fear, avoidance, anxiety, and depression. The last 5 items combine to form a Subscores related to psychosocial factors that suggest CBT is suitable as an intervention . SBST is currently being trialed in NHS 24 Scotland for MSK conditions.
Figure 3: Subgrouping and Care Plan
Targeting patient subgroups most likely to receive CBT can help improve outcomes and reduce costs. The SBST test performed by Hill et al. 2011 demonstrated increased health benefits coupled with reduced healthcare costs. Experiments show that by SBST and training Therapists delivered targeted interventions to each of the three subgroups of patients, resulting in an average direct savings of £34.39 per patient and indirect savings of £675 per patient compared to patients receiving current care. pain-related productivity and Social losses can be manifested through sick leave and repeated medical visits. A randomized controlled trial  conducted in 2005 found that CBT, in addition to physical therapy, reduced the average number of pain visits from 6 to 1 and reduced the percentage of sick days from 9-14% to 2-5% When comparing groups that received minimal treatment and CBT. Such evidence suggests that therapeutic interventions that take into account biopsychosocial models of patient care have the potential to reduce disability and lower the cost of care.
Evidence shows that the effectiveness of CBT is enhanced when targeted to the correct patient population. Tools like the SBST require a patient-centred approach combined with sound clinical reasoning to target those who are likely to benefit from them. With an adapted version of SBST includes other MSK conditions that are being trialled with NHS 24, and currently newly trained physiotherapists will benefit from CBT training to effectively use new information gained from patients. Physiotherapists are evidence-based practitioners who not only need Receive further training to incorporate CBT principles, but practicing physiotherapists wish to expand knowledge of CBT principles .
The Role of CBT in Multidisciplinary Teams and Families
CBT can also be used outside of the therapist-patient relationship. Some areas where allied health professionals (AHPs) can apply CBT include:
- Support for families of people with chronic and acute illness:
- Reassuring family members affected by chronic and acute conditions is critical to patient care and recovery .
- Programs aimed at including families in the care of chronically ill relatives can be implemented particularly in end-of-life settings. These programs can guide family members through goal setting, supportive communication skills, and provide them with tools to assist with monitoring Clinical symptoms and medication .
- For those with occupational threats, such as professional athletes or manual laborers, coping with potential loss of income can be extremely stressful for themselves and their families.
In order for the family to play a supportive role, a change in perception is often required. Unrealistic and irrational thoughts about a loved one’s prognosis can be detrimental to the healing process. Therefore, where possible, such beliefs should be addressed to reduce potential Any maladaptive behavior . For those with acute illnesses that may lead to loss of income or the concept of self-CBT, it may help to prevent anxiety and cognitive distortions (such as catastrophizing) and increase adherence to rehabilitation programs .
- Collaborate effectively with other members of MDT, especially in challenging settings such as palliative care oncology:
- When those working in a palliative care setting were interviewed about workplace stressors, more stressors were related to difficulties in the work environment and occupational roles of colleagues rather than interactions with patients and their families .
- For those working in high-stress healthcare fields, seeking support from colleagues is often more popular and more accessible than official support models .
By gaining insight into the cognitive and behavioral components of our own behavior, we can develop higher self-monitoring traits while enhancing empathy. This in turn may lead to further understanding of other professionals within MDT, allowing us to iron out any potential fluctuations Condition. Additionally, many of the environments that require physical therapy skills tend to be stressful and emotional. Therefore, we may need to engage in supportive behaviors and cognitive reasoning with colleagues.
- To ensure optimal individual mental health at the AHP:
- The Health and Safety Executive recognizes that there are many factors in the workplace that can stress the mental health of NHS professionals. These include: excessive demands lack of control lack of support poor work relationships role ambiguity and organizational change .
- The 2009 Boorman Review reported that the NHS lost 10 million working days to illness each year, costing the NHS around £555 million, with mental health and MSD being the main causes. Taken together, they are the leading cause of health-related early retirement in the NHS .
- The Work Foundation estimates that, in the UK, lost work time due to attendance due to poor mental health conditions is almost 1.5 times higher than sick leave absence due to mental health conditions .
By understanding their own cognitive state, AHPs may be able to overcome inherent stressors at work. Self-directed CBT has been documented to reduce an individual’s own stress, anxiety, depression, and cognitive dissonance . Since CBT combines The introspection of thought processes in cognitive therapy and the behavioral change goals of CBT in behavioral therapy can be useful tools in the physical therapist’s own development as competent and well-rounded professionals. Enhanced insight into maladaptive thoughts may reduce Mental health problems may lead to fewer working days lost in the NHS .
Applying CBT to Physiotherapy Practice
CBT principles can be applied in conjunction with current physical therapy practice. CBT also involves consideration of the following :
- Therapeutic Alliance
- Patients must see therapy as teamwork
- It is important for the therapist to provide empathetic warmth and genuine care by listening to and understanding how the patient is really feeling.
- Providing a realistic outlook
- Make sure the patient understands and agrees to the treatment being used.
- Encourage patients to take an active role in the recovery process by providing therapeutic homework.
- Goal setting
- Elicit SMART goals from the start to ensure patients understand what they are trying to achieve.
- The therapist’s goal should be to teach the patient the skills and techniques on how to be their own therapist.
- Time Limited
- Patients typically receive 6-14 sessions of treatment, during which the therapist aims to alleviate, address the patient’s most pressing concerns, and teach them skills to avoid relapse.
- Structured therapy
- To maximize efficiency and effectiveness, every meeting should be structured.
- Various techniques
- CBT uses a variety of techniques to meet an individual’s needs.
- Identify, evaluate and respond
- A patient may have hundreds of automatic thoughts each day, but it is important for the therapist to teach the patient to identify key cognitions and how to respond to them.
Evidence shows that CBT can benefit all aspects of the patient journey, not only the patient but also family members and the MDT. Current physical therapy education attempts to emphasize and root the practice of the ICF model. Integrate the CBT module into Current courses will emphasize the importance of combining biomedical and psychosocial models of healthcare. The many benefits of CBT are demonstrated throughout the proposal. These include enhancing the patient journey, promoting more effective practice, and ultimately Minimize healthcare costs. The example modules provided on this page demonstrate the simplicity and feasibility of implementing CBT modules.
- ↑ Jump up to:1.0 1.1 Beck J. Cognitive Therapy: Basics and Beyond, 2nd ed. New York: Guildford Press, 2011.
- ↑ Jump up to:2.0 2.1 Donaghy M, Nicol M, Davidson K, editors. Cognitive-behavioral interventions in physiotherapy and occupational therapy. Edinburgh: Elsevier, 2008.
- ↑ Gatchel RJ, Rollings KH. Evidence informed management of chronic low back pain with cognitive behavioural therapy. The Spine Journal 2008; 8(1):40–44.
- ↑ Turk D, Flor H. A cognitive-behavioral approach to pain management. In: Mcmahon S, Koltzenburg M, editors. Wall and Melzacks textbook of pain. London: Elsevier Churchill Livingstone, 1999. p1431-1441.
- ↑ WHO., 2013. International Classification of Functioning, Disability and Health (ICF)[online]. [viewed16 Novemeber 2013]. Available from: http://www.who.int/classifications/icf/en/
- ↑ Wright J, Basco M, Thase M. Learning cognitive-behaviour therapy: An illustrated guide. London: American psychiatric publishing inc, 2006.
- ↑ Foster N, Delitto A. Embedding psychosocial perspectives within clinical management of low back pain: Integration of psychosocially informed management principles into physical therapist practice – challenges and opportunities. Journal of American Physical Therapy Association 2011;91:790-803.
- ↑ Van Tulder MW, Ostelo R, Vlaeyen JWS, Linton SJ, Moreley SJ, Assendelft WJJ. Behavioral treatment for chronic low back pain: A systematic review within the framework of the Cochrane back review group. Spine 2000:25(20);2688-99.
- ↑ Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy and behavior therapy for chronic pain in adults, excluding headache. Pain 1999:80;1-13.
- ↑ Rossy LA, Buckelew SP, Dorr N, Hagglund KJ, Thayer JF, Mcintosh MJ, Hewett JE, Johnson JC. A meta-analysis of fibromyalgia treatment interventions. Annals of Behavioral Medicine 1999:21(2);180-91.
- ↑ Von Korff M, Moore JE, Lorig K, Cherkin DC, Saunders K, González VM, Laurent D, Rutter C, Comite, F. A randomized trial of a lay-led self-management group intervention for back pain patients in primary care. Spine 1998; 23(23): 2608–2615.
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- ↑ Linton SJ, Ryberg M. A cognitive-behavioural group intervention as prevention for persistent neck and back pain in a non-patient population: a randomized controlled trial. Pain 2001;90(1-2):83–90.
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- ↑ Lewin B, Cay EL, Todd I, Sorgal I, Gordfield, Bloomfield P. The Angina Management Programme: a rehabilitation treatment. British Journal of Cardiology 1995; 2: 221-226.
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- ↑ Lewis S, Tarrier N, Haddock G, Bentall R, Kinderman P, Kingdon D, Siddle R, Drake R, Everitt J, Leadley K, Benn A, Grazebrook K, Haey C, Akhtar S, Davies L, Palmer S, Faragher B, Dunn G. Randomised controlled trial of cognitive behavioural therapy in early schizophrenia: acute-phase outcomes. British Journal of Psychiatry 2002; 181(43):91-97
- ↑ Sveinsdottir V, Eriksen HR, Reme SE Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain. Journal of Pain Research 2012; 5:371-80
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- ↑ Eccleston C, Williams ACDC, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults (review). Cochrane Database of Systematic Reviews 2009:2;1-102.
- ↑ Keele University. STarT Back Screening Tool Website. http://www.keele.ac.uk/sbst/usingscoringthesbst/ (accessed 28 October 2013).
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- ↑ Hill JC, Whitehurst DGT, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomized controlled trial. Lancet 2011:378;1560-71.
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