Practical strategies for working with complex cases
Dr Stephen Barton, Hayley Tyson-Adams & Stephen Holland
NEW DATE
February 16th 2024
09.30 - 16.30
ABSTRACT
“Complex case” is a well-used phrase in CBT but what do we mean by it? Do we have a shared understanding of what it is? This workshop will explore what a complex case is and provide some clear guidance how to identify, formulate and respond to clinical complications.
Our basic view is that “complex case” is an over-used phrase. It gets used to describe a range of difficulties in providing CBT. This is very understandable because CBT is not an easy treatment to provide or receive. It takes a lot of training, skill and hard work to be a CBT therapist. It’s not easy. It takes a lot of trust, work and courage to benefit from CBT as a patient. It’s not easy. But difficulties are not necessarily complicated; they’re just difficult.
Complications arise when something obstructs the way that CBT usually works. It might be something unexpected or unusual. It might be factors that interact in a complicated way, for example, a client with panic disorder who is also receiving palliative care. Fear of death is usually over-estimated in clients with panic; the fact the client is nearing end of life is a complication that needs to be identified, formulated and worked with. It is not insurmountable; but it’s complicated. Standard CBT needs to be adjusted to address the complication.
It might be an issue in the client/therapist interaction, for example, a therapist who looks physically similar to the client’s abuser, so much so that the client feels unable to disclose the abuse. This is a real-life example that only came to light in a subsequent therapy. In this situation, the therapist’s appearance was a complication: it interacted with the client’s problems and obstructed the way that CBT usually works. The complexity was even higher because the therapist was unaware of it.
Working with this understanding of what complexity is, the workshop will explore two types of complication:
Problem complexity: when clients have multiple interacting problems. This can occur when clients have co-morbid disorders and it’s difficult to know what to prioritise. It can also be hard to stay focused on one target problem when other difficulties come to light during the therapy. Concurrent social and/or bio-medical problems can also disrupt the normal CBT treatment process.
Relational complexity: when there are complications in the therapeutic relationship. This occurs when something gets in the way of the collaboration needed for CBT to be effective. Client, therapist and service factors may all be at play. Sometimes the alliance barriers are apparent and understood, and sometimes they go un-noticed.
Goals
Reflect on one of your complex cases, past or current
Learn some key principles to identify and formulate complexity in CBT
Receive practical guidance on how to respond to complicated clinical sit
Observe role play demonstrations
Plan
Before the workshop, choose one of your complex cases, past or current, to reflect on during the day. There will be practical tasks throughout the day to consider different aspects of your case.
In the morning, we’ll explore what to do when clients have multiple problems, sometimes changing week to week, and it’s not obvious what to prioritise or how to stick with a target long enough for the client to benefit.
In the afternoon, we’ll explore what to do when there are complications in the therapeutic relationship – sometimes they’re obvious and sometimes they’re not.
Throughout the day, there will be clear guidance on do’s and don’ts and role-play demonstrations on how to address complications when they’ve been identified.
References
Barton, S & Armstrong, P. (2019). CBT for Depression: An Integrated Approach. Part IV, Complex Cases (pages 201-265)
Barton, S., Armstrong, P., Wicks, L., Freeman, E. & Meyer, T.D. (2017) Treating complex depression with cognitive behavioural therapy. The Cognitive Behavioural Therapist. Vol. 10. http://dx.doi:10.1017/S1754470X17000149
The Cognitive Behavioural Therapist (2017). Vol. 10: Special Issue - Working with Complexity in CBT
Stephen Barton
Hayley Tyson Adams
Stephen Holland
Bite-Sized CPD
A series of 4 on demand webinars
Dr Stephen Barton,
University of Newcastle
CBT for Difficult-to-treat Depression
Series of 4, £88.00
This webinar series is designed for every CBT therapist who has struggled to collaborate with and fully engage depressed people in CBT.
The symptoms of depression create major barriers to the delivery of CBT - this webinar series, based on years of careful clinical research, will give you new insights and skills to help you and your clients to tackle and overcome these barriers.
Each workshop is independent but we recommend you register for all 4 (click link below). To access individual workshops scroll down and click link on workshop of your choice
Webinars were delivered live on 18th & 25th January, 1st & 8th February 2023
Now available 'on demand' via our secure portal. Watch when you like and download all the resources
CBT for difficult-to-treat depression
Dr Stephen Barton,
University of Newcastle, UK
Abstract
Depression is often difficult to treat; it’s a recurrent disorder and many clients have lapses or relapses after making therapeutic gains. This is particularly true when clinical complexity is high, for example, when clients have adverse childhood experiences, co-morbidities, interpersonal problems and/or heightened risk.
For all clients, depression can get in the way of its own treatment. For example, CBT is unlikely to be fully delivered, or received, when clients:
- are passive in the therapeutic relationship;
- are having therapy to please someone else;
- go through the motions rather than engage in activities or experiments;
- ruminate about thoughts rather than reflect on them and test them out
This webinar series will explore four common types of difficulty with two combined aims:
Increase understanding of the client’s experience within the difficulty;
Consider different therapeutic strategies and responses.
The series will explore interpersonal, motivational, behavioural and cognitive factors, and the overarching message is that difficulties need to be understood and tackled pro-actively to stop them becoming therapeutic tensions and barriers to change. Video demonstrations will be used throughout to illustrate different therapeutic strategies.
References
Barton, S., Armstrong, P., Wicks, L., Freeman, E. & Meyer, T.D. (2017) Treating complex depression with cognitive behavioural therapy. The Cognitive Behaviour Therapist. Vol. 10. http://dx.doi:10.1017/S1754470X17000149
Barton, S. & Armstrong, P. (2019) CBT for Depression: An Integrated Approach. Sage
Barton, S.B., Armstrong, P.V., Robinson, L. & Bromley, E.C.H. (in press, 2022). CBT for Difficult-to-Treat Depression: Self-Regulation Model. Cognitive and Behavioural Psychotherapy
Barton, S.B., Armstrong, P.V., Holland, S. & Tyson-Adams, H. (in press, 2022). CBT for Difficult-to-Treat Depression: Single Complex Case. The Cognitive Behavioural Therapist
Building an alliance that works
A good-enough working alliance is essential for CBT to be effective. This webinar will explore some of the interpersonal consequences of depression, such as keeping people at a distance, giving others responsibility, or excessive re-assurance seeking. Without an appropriate therapeutic response, these can become barriers to collaboration. Therapists need to adjust their interpersonal style accordingly, based on client need, optimizing the balance of support and change in different situations. This can mean acting against the interpersonal ‘pull’ of the client, sometimes risking the alliance rather than protecting it at all costs.
Overcoming problems with motivation
Depression impairs motivation but it’s not always as simple as having less energy or feeling un-motivated. Some motivational impulses are stronger in depression, for example, the urge to avoid tasks, to hide from others or to follow internal ‘shoulds, oughts and musts’. Conflicting motivational states are common. This webinar will explore ways of helping your client reflect on their motivation and learn more about it. The aim is to strengthen approach impulses, the urges that provoke goal-directed activity. For some clients, activating behaviour is sufficient to build motivation, but for others their self-identity and life-goals need to be engaged more explicitly.
Getting more out of behavioural experiments
Most experiments with depressed clients elicit their predictions and wait to see if the outcomes are as negative as expected. This can be a powerful source of cognitive change, but it is only one approach. It relies on disconfirmation: that events will be less negative than the client predicts. An alternative approach relies on confirmation, encouraging the client to influence preferred outcomes. When this is effective, clients learn that they can influence what they would like to happen. This webinar will explore the pros and cons of testing predictions versus influencing preferences, with the aim is to increase the range of therapeutic options available to therapists.
Overcoming rumination with mental freedom
Traditional cognitive therapy targets thought-content: what the client believes and how strongly they believe it. But depressed clients don’t just believe negative thoughts; they engage in unhelpful thought-cycles about them, sometimes called rumination. Rumination maintains depression and is a barrier to paying attention, processing information in depth and creating new memories. It impedes the learning needed for CBT to work. Mental freedom is a meta-cognitive approach: it explores the client’s relationship with their mind. Instead of challenging thoughts and beliefs, it seeks to maximise self-mind co-operation. In practice, this means conducting experiments across a range of cognitive processes to find out what works best in different situations. When mental freedom increases, rumination and other unhelpful processes decrease.
Dr Stephen Barton
Dr Stephen Barton is Consultant Clinical Psychologist at the Regional Affective Disorders Service in Newcastle. He is former director of the Newcastle CBT Diploma and has a longstanding interest in CBT for complex mood disorders. He is currently conducting clinical trials of Self-Regulation CBT for difficult-to-treat depression. His other interests include clinical complexity, interpersonal processes, supervision and personal development.