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• Preface
• Introduction
• How to use this book
• About the author
• Acknowledgements
• SECTION A – INTRODUCTION
• Chapter 1 – Introduction to CBT
• What is CBT?
• Why is CBT important in primary care?
• Access to CBT
• What is ‘10 Minute CBT’?
• Basic principles of CBT
• Different perspectives for the same situation
• Key learning points
• Chapter 2 – Adapting CBT for general practice
• Practical aspects of incorporating CBT into brief consultations
• Choice of patients
• Should any patients be avoided?
• Managing time pressures
• Reflecting on GP behaviour
• Opening a ‘can of worms’
• Keeping a realistic attitude
• Learning and applying CBT skills in the general practice setting
• Key learning points
• Chapter 3 – The cognitive-behavioural model
• Introducing the cognitive-behavioural model
• Understanding thoughts and cognitions
• What are thoughts?
• Chains of thoughts
• Feelings and emotions
• Rating feelings
• The relationship between thoughts and feelings
• Separating thoughts from feelings
• Connections between thoughts and feelings
• CBT and positive thinking
• The role of behaviour
• Breaking vicious cycles with behavioural changes
• Physical reactions and symptoms
• Environment, social circumstances and culture
• Early experiences
• Social and environmental circumstances
• Life events
• Cultural and other social factors
• Developing a ‘case formulation’
• Key learning points
• Chapter 4 – Introducing a cognitive-behavioural approach to patients 33
• Getting started
• Using a written CBM chart
• Use of written records: what to say
• Talking through the CBM
• Discussing thoughts
• Discussing feelings
• Looking at behaviour
• Physical symptoms
• Social and environmental factors
• Summarising what you have heard
• Key learning points
• Chapter 5 – Communication skills for CBT
• Effective communication in CBT
• The therapeutic relationship in CBT
• Building collaborative relationships
• Lifting the ‘do something’ pressure
• Using guided discovery to build collaboration
• Expressing empathy
• CBT communication skills
• Problem-focused approach
• Problem-focused approach: what to say
• Identify a specific example of key problems
• Identify a specific example: what to say
• Explore the example using the CBM
• Summarise and highlight links
• Highlighting links
• Handover questions
• Giving empowering explanations
• Giving empowering explanations: what to say
• Setting and reviewing homework
• Following up homework
• Agreeing homework: what to say
• Overcoming difficulties with homework
• Ask for feedback/check patient understanding
• Key learning points
• SECTION B – SKILLS
• Chapter 6 – Coping with negative thoughts
• How can changing thoughts help?
• Unhelpful thinking styles
• The problem with trying not to think negatively
• Distraction
• Difficulties with using distraction
• Broadening perspectives on difficult situations
• Evaluating negative thoughts
• Identifying negative thoughts
• Evaluating the evidence for thoughts
• Using written thought records
• Challenging unhelpful thoughts using written thought records
• Overcoming difficulties with thought records
• Key learning points
• Chapter 7 – Changing unhelpful behaviour
• The importance of changing behaviour
• Involving patients in behavioural changes
• Setting realistic expectations for improvement
• Behavioural activation
• Using ‘behavioural experiments’
• Identifying relevant behavioural experiments
• Designing and implementing effective behavioural experiments
• 1. Identify the problem
• 2. Plan behavioural changes
• 3. Try out new behaviour and observe what happened
• 4. Review and reflection
• Key learning points
• Chapter 8 – Goal setting and overcoming resistance to change
• Goal setting
• Values and personal benefits for making change
• Plan rewards
• Building confidence to achieve goals
• Overcoming barriers to change
• Reviewing goals
• Coping with setbacks
• Pacing
• The boom and bust cycle
• Pacing – an alternative to boom and bust
• Motivational interviewing
• Key communication skills for MI
• Develop discrepancy
• Discuss the importance of change
• Cost–benefit analysis
• Notice and encourage ‘change talk’
• Emphasise autonomy
• Key learning points
• Chapter 9 – Overcoming practical problems: problem-solving approaches
• What is ‘problem-solving’?
• When to use a problem-solving approach
• Introducing problem-solving to patients
• The Eight Steps of Problem-Solving
• Step 1: Make a list of problems
• Step 2: Choose a problem to solve
• Step 3: Define the problem clearly
• Step 4: Generate solutions to problems
• Step 5: Choose a solution
• Step 6: Make an action plan
• Step 7: Carry out the plan
• Step 8: Review what happened
• Reviewing difficulties
• The problem-solving cycle
• Key learning points
• Chapter 10 – Deeper levels of belief: core beliefs and rules
• Different types of thought
• Where do rules and core beliefs come from?
• Unhelpful rules and core beliefs
• ‘Self-fulfilment’ of rules and core beliefs
• Why do GPs need to know about core beliefs and rules?
• Maintaining emotional safety
• Identifying core beliefs and rules
• Changing unhelpful rules
• Using behavioural experiments to overcome unhelpful rules
• Changing core beliefs
• Key learning points
• Chapter 11 – Mindfulness and acceptance
• What is mindfulness?
• Approaches to mindfulness
• Acceptance and commitment therapy
• Experiential avoidance
• Developing mindfulness
• Being in contact with the present moment
• Acceptance
• Cognitive defusion
• Finding the observer self
• Commitment and action towards living a values-based life
• More mindfulness exercises
• Key learning points
• SECTION C – CLINICAL APPLICATIONS
• Chapter 12 – Depression
• Understanding depression
• Cognitive-behavioural therapy for depression
• A combined approach to depression for primary care
• Understanding depression
• Typical thoughts and thinking styles in depression
• Feelings and emotions in depression
• Biological factors and physical symptoms in depression
• Altered behaviour in depression
• The role of environmental and social factors in depression
• Vicious cycles in depression
• Using 10 Minute CBT with depressed patients
• Empowering explanations in depression
• Making behavioural changes in depression
• Behavioural activation in depression
• Physical exercise
• Coping with negative thoughts in depression
• Distraction
• Exploring and reframing negative thoughts
• Mindfulness
• Key learning points
• Chapter 13 – Insomnia
• What is insomnia?
• What are the normal stages of sleep?
• How much sleep do we really need?
• Causes of insomnia
• Background factors, life events and the physical environment
• Physical problems and medication
• Thoughts and thinking styles
• Feelings and emotions
• Unhelpful behaviour
• Management of insomnia
• Sleep hygiene
• Create a good sleeping environment
• Using a sleep diary
• Using a sleep diary to improve sleep efficiency
• Managing worry thoughts
• Stop trying to sleep
• Put the worries aside
• Evaluating unhelpful thoughts
• Problem-solving
• Meditation and relaxation
• Key learning points
• Chapter 14 – Anxiety disorders
• Panic disorder
• Thoughts and cognitive factors in panic
• Feelings in panic disorder
• Physical symptoms in panic disorder
• The role of behaviour in panic disorder
• Triggers for panic attacks
• Vicious cycles in panic disorder
• Giving empowering explanations in panic disorder
• Cognitive strategies to manage panic attacks
• Behaviour change in panic disorder
• Physical strategies for reducing panic
• Generalised anxiety disorder
• Typical features of GAD
• CBT approaches to GAD
• Mindfulness, relaxation and exercise
• Social anxiety
• Typical features of social anxiety
• CBT approaches to social anxiety
• Obsessive compulsive disorder
• CBT interventions for OCD
• Key learning points
• Chapter 15 – Health anxiety and medically unexplained symptoms 205
• Introduction
• Medically unexplained symptoms
• Health anxiety and MUS in primary care
• CBT for health anxiety and MUS
• A CBT approach to understanding health anxiety
• Background/environmental factors
• Development of unhelpful core beliefs and rules about health
• Thoughts in health anxiety
• Feelings and emotions
• Physical symptoms and reactions
• The role of behaviour
• Managing MUS and health anxiety
• Steps for a CBT approach to MUS
• Build a trusting relationship with patients
• Review and summarise the patient’s notes
• Carry out a longer ‘status consultation’
• Provide empowering explanations for key symptoms
• Broaden the agenda
• Negotiate the next steps (medical and non-medical treatments)
• Check patient understanding
• CBT strategies for managing MUS
• Behavioural strategies in health anxiety
• Cognitive strategies for health anxiety
• Key learning points
• Chapter 16 – Chronic physical disease
• The psychological impact of chronic disease
• The role of health beliefs in adjusting to chronic disease
• Using 10 minute CBT with physical illness and disability
• Acceptability of psychological approaches to physical disorders
• Managing complex physical and emotional problems
• Write a problem list
• Coping with uncertainty
• Strategies for managing uncertainty
• Changes in physical appearance
• Coping with unpleasant physical symptoms
• Breathlessness in respiratory conditions
• Key learning points
• Chapter 17 – Functional somatic disorders
• Chronic pain
• What is chronic pain?
• Who gets chronic pain?
• Development of chronic pain
• CBT model of chronic pain
• Vicious cycles in chronic pain
• Management of chronic pain
• Chronic fatigue syndrome
• CBT model of chronic fatigue syndrome
• Management of CFS
• Irritable bowel syndrome
• CBT model of irritable bowel syndrome
• Management of IBS
• Key learning points
• Chapter 18 – Low self-esteem
• What is low self-esteem?
• The cognitive-behavioural model of low self-esteem
• Thoughts and beliefs in low-self esteem
• Feelings
• Behaviour
• Physical symptoms
• Environment and social factors
• The development of low self-esteem
• Overcoming low self-esteem
• Discovering the internal bully
• The rational mind
• The compassionate mind
• Countering negative thoughts and self-criticism
• Using written thought records
• Identifying personal qualities
• Positive diaries
• Changing unhelpful behaviour in low self-esteem
• Increasing activity levels
• Behavioural experiments
• Developing assertiveness
• Making assertive statements and requests
• Learning to say ‘no’
• Dealing with criticism
• Key learning points
• Chapter 19 – Managing ‘heartsink’
• What is ‘heartsink’?
• Who gets heartsink?
• Taking responsibility for heartsink reactions
• The CBM approach to heartsink
• Feelings associated with heartsink
• Thoughts
• Behaviour
• Physical symptoms
• Environmental factors
• Making changes in heartsink responses
• Evaluating thoughts and reframing unhelpful thinking
• Helpful thoughts and attitudes
• Being ‘good enough’
• Looking at the bigger picture: putting heartsink into perspective
• Managing uncertainty
• Changing behaviour in heartsink
• Using the CBM for teaching, training and mentoring
• Key learning points
• References and further reading
• Training resources for health professionals
• Index