This clip contains an excerpt from the DVD “10 Minute CBT in practice: Physical Health and long-term conditions”. In this scenario, a GP demonstrates simple CBT strategies for managing a patient with chronic back pain.
Available on the Apple App Store today, Molehill Mountain is the first evidence-led smartphone app aiming to help autistic adults understand and self-manage their own anxiety. The app has been developed by UK research charity Autistica and researchers at King’s College London with input from autistic people.
Molehill Mountain will launch as part of a digital learning package on anxiety and autism which includes an email course and supporting web content.
Research studies show that 40-50% of autistic people suffer with anxiety disorders – vastly higher rates than in non-autistic people. Helping people understand the causes of anxiety and the reasons for their symptoms is key to managing it better.
Molehill Mountain is based on Cognitive Behaviour Therapy (CBT) approaches adapted for autistic people. It builds on the latest research into anxiety in autism and puts these techniques into the hands of autistic adults across the UK.
The app originated from a hackathon held at Deutsche Bank when Autistica was one of its Charities of the Year in 2016-17. More than 150 of the bank’s technology and design experts competed to develop a prototype, with all coding created donated to Autistica. It has also received funding from the Maudsley Charity the ‘Worshipful Company of Information Technologists’ Charity and The Pixel Fund.
Jon Spiers, Chief Executive at Autistica, explains: ‘Too often autistic people receive inappropriate anxiety support and sometimes they’re unable to access any support at all. We wanted to offer something practical that can be used whenever and wherever it’s needed. Many autistic people have a real affinity with tech and our autistic testers and developers told us that personalisation was important, so an app seemed like the perfect solution.’
Molehill Mountain gets users to track their worries and how they’re feeling through a quick dailycheck-in. The user is prompted to open the app to play Molehill Mountain, an activity designed to identify and capture any worries. Completing the activity unlocks a daily tip about anxiety and autism. The user is then asked three simple questions about their day and given the option to add more context to a daily diary. At each check-in, the user tracks their progress up Molehill Mountain and reviews their stats, tips and diary entries through a dashboard. The app delivers its programme over 14 check-ins but can be used for longer. Users can also share their progress with a trusted supporter.
Despite high potential and interest for clinical mental health apps, research suggests that many fail because of low engagement levels. Users report that these apps are often unhelpful, don’t addresstheir problems or feel insecure or untrustworthy. Autistica and King’s College London worked closely with autistic people and developers to ensure that Molehill Mountain is easy to use, engaging, relevant and secure.
As someone with lived experience of anxiety, Amy helped Autistica to develop the app. She says: ‘I enjoyed getting involved – it is great to have my needs heard. I am pleased that research is being used to create a practical tool to help people like me cope better in everyday life.’
The team are taking an iterative approach to developing Molehill Mountain. They will continue to test and learn with users of the app to plan new features and other improvements. Professor Emily Simonoff from the Institute of Psychiatry, Psychology & Neuroscience at King’s College London worked on the anxiety research that formed the basis of the app: ‘We based the content of Molehill Mountain on adapted cognitive-behavioural therapy (CBT) principles, as there is good evidence that CBT can help to reduce anxiety symptoms in people with autism. It is not clear yet how effective Molehill Mountain will be for helping people to manage their anxiety, but we will be following a group of users to see how they get on.’
CBT and chronic pain
By teaching patients better strategies for coping with chronic pain, cognitive behavioral therapy (CBT) is a valuable treatment alternative for the millions of Americans taking opioids for noncancer pain, according to an article in the Journal of Psychiatric Practice. The journal is published by Wolters Kluwer.
“Cognitive behavioral therapy is a useful and empirically based method of treatment for pain disorders that can decrease reliance on the excessive use of opiates,” write Drs. Muhammad Hassan Majeed of Natchaug Hospital, Mansfield Center, Conn., and Donna M. Sudak of Drexel University College of Medicine, Philadelphia. They discuss evidence supporting the use of CBT to avoid or reduce the use of opioids for chronic pain.
CBT Offers Effective, Safer Alternative to Opioids for Chronic Pain
Rising use of opioid (sometimes called opiate) medications to treat chronic noncancer pain is a major contributor to the US opioid crisis. But despite the aggressive marketing and prescribing of these powerful painkillers, there has
been little change in the amount and severity of pain reported by Americans over the past decade. “There is no evidence that supports the use of opioids for the treatment of chronic pain for more than one year, and chronic use increases the serious risks of misuse, abuse, addiction, overdose, and death,” Drs. Majeed and Sudak write.
They believe that CBT is an important alternative to opioids for treatment of chronic pain. The goal of CBT is to help patients change the way they think about and manage their pain. The idea is not that pain (in the absence of tissue damage) “is all in your head”–but rather that all pain is “in the head.” Cognitive behavioral therapy helps patients understand that pain is a stressor and, like other stressors, is something they can adapt to and cope with.
Interventions may include relaxation training, scheduling pleasant activities, cognitive restructuring, and guided exercise–all in the context of an “empathic and validating” relationship with the therapist. These interventions “have the potential to relieve pain intensity, improve the quality of life, and improve physical and emotional function,” according to the authors.
“Therapy helps the patient see that emotional and psychological factors influence perception of pain and behaviors that are associated with having pain,” Drs. Majeed and Sudak write. “Therapy…puts in place cognitive and behavioral strategies to help patients cope more successfully.”
The authors cite several recent original studies and review articles supporting the effectiveness of CBT and other alternative approaches for chronic pain. Studies suggest that CBT has a “top-down” effect on pain control and perception of painful stimuli. It can also normalize reductions in the brain’s gray matter volume, which are thought to result from the effects of chronic stress.
Cognitive behavioral therapy is moderately effective in reducing pain scores, while avoiding or reducing the opioid risks of overuse, addiction, overdose, and death. It can be used as a standalone treatment; in combination with other treatments, including effective non-opioid medications; or as part of efforts to reduce the opioid doses required to control chronic pain.
Unfortunately, CBT and other nondrug treatments are underused due to unfamiliarity, time pressure, patient demands, ease of prescribing medications, and low reimbursement rates. Drs. Majeed and Sudak note that significant investment of resources will be needed to train practitioners and to widely integrate the use of CBT into chronic pain treatment. The authors suggest that the President’s Commission on the opioid crisis might fund such training programs as a preventive strategy to curb opioid abuse.
“There is a need for a paradigm shift from a biomedical to a biopsychosocial model for effective pain treatment and prevention of opioid use disorder,” Dr. Majeed comments. “Increased use of CBT as an alternative to opioids may help to ease the clinical, financial, and social burden of pain disorders on society.”
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) can help you make sense of overwhelming problems by breaking them down into smaller parts.
In CBT, problems are broken down into five main areas:
situations
thoughts
emotions
physical feelings
actions
CBT is based on the concept of these five areas being interconnected and affecting each other. For example, your thoughts about a certain situation can often affect how you feel both physically and emotionally, as well as how you act in response.
CBT differs from many other psychotherapies because it’s:
pragmatic – it helps identify specific problems and tries to solve them
highly structured – rather than talking freely about your life, you and your therapist discuss specific problems and set goals for you to achieve
focused on current problems – it’s mainly concerned with how you think and act now rather than attempting to resolve past issues
collaborative – your therapist won’t tell you what to do; they’ll work with you to find solutions to your current difficulties
There are helpful and unhelpful ways of reacting to a situation, often determined by how you think about them.
For example, if your marriage has ended in divorce, you might think you’ve failed and that you’re not capable of having another meaningful relationship.
This could lead to you feeling hopeless, lonely, depressed and tired, so you stop going out and meeting new people. You become trapped in a negative cycle, sitting at home alone and feeling bad about yourself.
But rather than accepting this way of thinking you could accept that many marriages end, learn from your mistakes and move on, and feel optimistic about the future.
This optimism could result in you becoming more socially active and you may start evening classes and develop a new circle of friends.
This is a simplified example, but it illustrates how certain thoughts, feelings, physical sensations and actions can trap you in a negative cycle and even create new situations that make you feel worse about yourself.
CBT aims to stop negative cycles such as these by breaking down things that make you feel bad, anxious or scared. By making your problems more manageable, CBT can help you change your negative thought patterns and improve the way you feel.
CBT can help you get to a point where you can achieve this on your own and tackle problems without the help of a therapist.
Exposure therapy is a form of CBT particularly useful for people with phobias or obsessive compulsive disorder (OCD).
In such cases, talking about the situation isn’t as helpful and you may need to learn to face your fears in a methodical and structured way through exposure therapy.
Exposure therapy involves starting with items and situations that cause anxiety, but anxiety that you feel able to tolerate. You need to stay in this situation for one to two hours or until the anxiety reduces for a prolonged period by a half.
Your therapist will ask you to repeat this exposure exercise three times a day. After the first few times, you’ll find your anxiety doesn’t climb as high and doesn’t last as long.
You’ll then be ready to move to a more difficult situation. This process should be continued until you have tackled all the items and situations you want to conquer.
Exposure therapy may involve spending six to 15 hours with the therapist, or can be carried out using self-help books or computer programs. You’ll need to regularly practice the exercises as prescribed to overcome your problems.
CBT can be carried out with a therapist in one-to-one sessions or in groups with other people in a similar situation to you.
If you have CBT on an individual basis, you’ll usually meet with a CBT therapist for between five and 20 weekly or fortnightly sessions, with each session lasting 30-60 minutes.
Exposure therapy sessions usually last longer to ensure your anxiety reduces during the session. The therapy may take place:
in a clinic
outside – if you have specific fears there
in your own home – particularly if you have agoraphobia or OCD involving a specific fear of items at home
Your CBT therapist can be any healthcare professional who has been specially trained in CBT, such as a psychiatrist, psychologist, mental health nurse or GP.
The first few sessions will be spent making sure CBT is the right therapy for you, and that you’re comfortable with the process. The therapist will ask questions about your life and background.
If you’re anxious or depressed, the therapist will ask whether it interferes with your family, work and social life. They’ll also ask about events that may be related to your problems, treatments you’ve had, and what you would like to achieve through therapy.
If CBT seems appropriate, the therapist will let you know what to expect from a course of treatment. If it’s not appropriate, or you don’t feel comfortable with it, they can recommend alternative treatments.
After the initial assessment period, you’ll start working with your therapist to break down problems into their separate parts. To help with this, your therapist may ask you to keep a diary or write down your thought and behaviour patterns.
You and your therapist will analyse your thoughts, feelings and behaviours to work out if they’re unrealistic or unhelpful and to determine the effect they have on each other and on you. Your therapist will be able to help you work out how to change unhelpful thoughts and behaviours.
After working out what you can change, your therapist will ask you to practise these changes in your daily life. This may involve:
questioning upsetting thoughts and replacing them with more helpful ones
recognising when you’re going to do something that will make you feel worse and instead doing something more helpful
You may be asked to do some “homework” between sessions to help with this process.
At each session, you’ll discuss with your therapist how you’ve got on with putting the changes into practice and what it felt like. Your therapist will be able to make other suggestions to help you.
Confronting fears and anxieties can be very difficult. Your therapist won’t ask you to do things you don’t want to do and will only work at a pace you’re comfortable with. During your sessions, your therapist will check you’re comfortable with the progress you’re making.
One of the biggest benefits of CBT is that after your course has finished, you can continue to apply the principles learned to your daily life. This should make it less likely that your symptoms will return.
A number of interactive software programs are now available that allow you to benefit from CBT with minimal or no contact with a therapist.
The main program currently approved for use by the NHS is Beating the Blues, which is approved for treating mild to moderate depression.
However, there are many similar computerised CBT (CCBT) packages that may also be effective.
Some people prefer using a computer rather than talking to a therapist about their private feelings. However, you may still benefit from occasional meetings or phone calls with a therapist to guide you and monitor your progress.
Read more about self-help therapies.
Multiple Sclerosis Awareness Month
Leonie Martin has relapsing remitting multiple sclerosis (MS). She resigned from her job in management seven years ago after a series of relapses and cognitive problems left her unable to carry out her role. She explains how she learnt to manage her symptoms.
“When I was diagnosed with MS I tried to ignore it. I had a busy, hectic lifestyle and a well-paid job in office management at a local school.
“I thought I’d be able to manage my MS and that my lifestyle wouldn’t have any effect on my symptoms, but problems soon started to occur. I would be in the middle of an important presentation when my mind would suddenly go blank. I found concentrating extremely difficult; if I was interrupted while in the middle of something, I would need to start from the beginning again.
“I lost the ability to delegate work to my staff, mainly because I couldn’t keep track of what I’d asked, and I began taking unfinished work home so I could concentrate on it in the evening. I could no longer multi-task and gradually lost all sense of perspective – I would regularly break down in floods of tears at my desk, which was unsettling for my colleagues.
“I knew the problems were connected to my MS, as I’d been doing the job very capably for years – and I think it was because of this that my employer and colleagues struggled to understand. I became anxious, paranoid and depressed, and two years after my diagnosis, decided to leave work. At the time, I was having three relapses a year and my neurologist prescribed me weekly beta interferon injections.
“Following a full neuropsychological assessment by a specialist, I became involved in a cognitive behavioural therapy (CBT) pilot study. The course helped me understand more about managing my symptoms and showed me how to focus more on what I could do rather than what I couldn’t. I learnt to pace myself more and be kinder to myself – refraining from getting angry when I forgot to do something.
“I found that by splitting my day into three sections – morning, afternoon and evening – I could manage my fatigue, and therefore my cognitive problems and mood swings. Now I know that I can’t do something in all three sections, so if I’m out to dinner with friends on an evening, I’ll sleep in the afternoon. I also try to exercise more, but have to ensure I build in a rest period afterwards.
“I’ve learnt more about the types of fatigue and now understand that applying a lot of concentration to something for a period of time can be as exhausting as standing all afternoon. I need to get the right balance and think about my daily choices.
“I’m now self employed as a freelance writer – it’s flexible and has reduced my stress levels and relapses. I haven’t had a major flare-up in three years, but understandably it’s had a major impact on the family in terms of finances.
“Cognitive behavioural therapy worked for me – but it’s not a magic wand. You need to be open-minded and want to learn how to get the best out of your own circumstances. You also have to be prepared to commit time and energy, both during the sessions and at home in between.
“I wish I had known about CBT earlier – I learnt to deal with my symptoms the hard way, but I’m happy that I’ve now found the right balance.”