The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core Components
Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT, and are used in the treatment of a variety of mental health disorders, including anxiety and depression. This therapy recognises the interrelationship between thoughts, beliefs, and behaviours, and how alterations in one domain can impact other domains. CBT therefore identifies, challenges, and modifies dysfunctional cognitive structures, facilitating emotional and behavioural changes.
Core CBT components can include;
- Psychoeducation: To provide information on the cognitive behavioural model, the patient’s illness and symptoms, as well as the rationale behind application of CBT
- Cognitive restructuring: To address distorted thoughts and beliefs. It’s four key steps include; 1) Identifying negative automatic thoughts (NATs) (i.e. problematic cognitions); 2) Identifying the distorted cognitions within the NATs; 3) Applying Socratic dialogue to dispute the NATs; 4) Providing logical rebuttals for the NATs
- Behavioural techniques: To alter negative behavioural patterns. It can consist of; 1) Activity scheduling and graded task assignments to establish daily routine, increase pleasurable experiences, and enhance problem solving skills; and 2) Behavioural experiments to gather evidence against the use of ineffective behaviours (e.g. safety behaviours)
- Exposure-based techniques: To alter the pathological fear structure by helping patients face their fears or triggers and helping them incorporate corrective associations in the fear memory. This in turn can reduce distorted associations and fear responses (e.g. escape, avoidance, and psychophysiological responses). Exposure based techniques can be imaginal, in vivo and interoceptive.
CBT can also include stress management to help patients minimise physiological arousal and promote relaxation; and tolerance of uncertainty to help patients (with anxiety disorders e.g. GAD) develop beliefs about uncertainty that are less negative and persistent. In the perinatal context, standard components of CBT will include integration of planning and support for the postpartum needs, whilst the patient receives treatment in the antenatal period. Hence, it is delivered in the context of pregnancy and caring for an infant, and can include specific information on perinatal mental health disorders and symptoms; pregnancy-related cognitions and attitudes; infants needs and behaviours in the first months after birth; constraints surrounding behavioural activation; and application of strategies that can improve communication and social support.
CBT is present-centred, and therefore focuses on the “here and now” challenges. It involves setting of realistic goals that have been mutually agreed between the therapist and patient. It therefore benefits from a collaborative therapeutic relationship between therapist and patient, as this facilitates achievement of the goals of the intervention (e.g. identification of problems, learning of relevant skills, and application of learned skills to manage identified problems). CBT is time-limited and is typically delivered over 5-20 sessions, with each session lasting about 30-60 minutes. The structured sessions are delivered weekly or fortnightly. CBT has homework components as these provide opportunities for patients to challenge themselves between sessions, and to generalise the skills learnt to their everyday lives.
Fidelity
NICE recommends that interventions in the perinatal period should be delivered by competent practitioner(s) with ongoing supervision. The intervention(s) should be delivered as per validated manual, and that stipulated content and structure are adhered to in order to ensure consistency in delivery of intervention. The use of competence frameworks developed from the treatment manual should also be considered. Treatment adherence and practitioner competence should be monitored and evaluated using appropriate measures, e.g. via recording of treatment sessions and auditing of recorded sessions. Rating scales like the Cognitive Therapy Rating Scale- Revised (CTS-R, Blackburn et al. 2001) can be used to assess therapist fidelity to treatment. Raters should be trained in CBT and should consider the relevance of the formulation and change methods.
For facilitated self-help CBT delivered to women in the perinatal period, NICE recommends provision of appropriate written reading materials or media support to allow access. Women accessing this service should be supported by trained practitioner, and the intervention should be delivered over a prescribed number of sessions (e.g. 6-8 sessions over 9-12 weeks for subthreshold depressive symptoms, mild depression and moderate depression; or in a total of 2 to 3 hours over 6 sessions for persistent subthreshold anxiety symptoms).
Modifiable Components
Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT, which can include Rational Emotive Behaviour Therapy (REBT), Dialectical Behaviour Therapy (DBT), metacognitive therapy, cognitive processing, and mindfulness-based cognitive therapy. CBT has been applied in the treatment of mental health disorders including depression and a range of anxiety disorders (e.g., generalized anxiety disorder, social anxiety disorder), either as transdiagnostic CBT (to treat a range of disorders) or disorder specific CBT. CBT can be delivered in individual or group formats. Delivery can be face-to-face (e.g. at community mental health centres, outpatient clinic settings, hospitals, and schools); virtual (via videoconference); or via online/ internet-based self-help programmes/ courses. As self-help interventions, CBT is delivered with varying levels of therapist’s assistance. CBT can be modified to meet the unique needs of women in the perinatal period, as it can be tailored to consider the beliefs, expectations, associated behaviours, and challenges that women report in this period.
Supports - Rating: 5
5 - Well Supported
Comprehensive resources are available to support implementation, including resources for building the competency of staff and organisational practice as a standard part of the intervention
Support for Organisation / Practice
Implementation Support
Implementation support is provided mainly by trained supervisors who support the application of CBT within each therapist’s practice. Support for implementing CBT is available through the NES Psychology and CAMHS workstreams, including webinars, CPD events and supervisor training.
Start-up Costs
There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. Costs apply when training is provided by private organisations.
Building Staff Competency
Qualifications Required
Staff will usually hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine) and will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level).
Training Requirements
Cognitive Behavioural Therapy (CBT) training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Additional training in CBT is available through the NES Psychology Trauma and CAMHS workstreams.
Supervision Requirements
Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and has completed the following pathway of supervision training:
- NES Generic supervision competences training (GSC) (or equivalent)
- NES Specialist Supervision Training: CBT (adult or child focus)
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (For further information click here).There is additional training available that specifically supports CBT supervision skills.
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Theory of Change
Cognitive Behavioural Therapy is based on theories that include:
- Cognitive theory: This theory recognises the interrelationship between thoughts, feelings, and behaviours, and contributory role of maladaptive cognition patterns in the aetiology of maladaptive affect and behaviours. Cognitive theory therefore proposes identifying, challenging and altering distorted cognitions, which can facilitate alterations to problematic emotions and behaviours.
- Emotional processing theory: This theory poises that cognitive fear structures retain information about fear stimulus, fear responses, and their meaning. Fear structures can become pathological when the stimulus or responses do not correlate with their meaning in reality, resulting in the activation of fear structures even on encounter with safe stimulus that are similar to the feared one. This theory proposes the alteration of the pathological fear structure by helping patients face their fears or triggers, and helping them incorporate corrective associations in the fear memory, in turn reducing distorted associations and fear responses.
Research Design & Number of Studies
A number of studies have reported the effectiveness of CBT in the treatment of perinatal mental health disorders. Some of the best available evidence include five systematic literature reviews and meta-analyses that evaluated the effectiveness of CBT delivered in-person and remotely to women in the perinatal period.
Outcomes Achieved
Compared to the control group who did not receive CBT, the following outcomes were reported;
- Significantly reduced postnatal/ postpartum depression symptoms at post-treatment (Lau et al, 2017; Sockol et al, 2015) and in the long-term (>3 months) (Roman et al, 2020; Huang et al. 2018)
- Significantly reduced antenatal depression symptoms at post-treatment and postpartum (<4 months) (Li et al, 2020)
- Significantly reduced postnatal depression diagnosis in the short and long-term (i.e. immediately after treatment and maintained for >3 months) (Huang et al, 2018)
- Significantly reduced postnatal/postpartum stress at post-intervention (Huang et al, 2018; Lau et al, 2017)
- Significantly reduced anxiety symptoms at post-intervention (Lau et al, 2017)
Need
Comparable Population
CBT has been shown to be effective in the treatment of non-psychotic perinatal mental health disorders (including anxiety and/or depression) when delivered in pregnancy and within one-year of the postnatal period.
Desired Outcome
CBT has been shown to effectively reduce perinatal depression, anxiety and stress symptoms, as well as depression diagnosis, at post-treatment and follow-up.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT, and are used for the treatment of a variety of mental health disorders, including anxiety and depression. It identifies, challenges, and modifies dysfunctional cognitive structures, facilitating emotional and behavioural changes. CBT is based on theories that can include cognitive theory and emotional processing theory.
Priorities
CBT can include the delivery of sessions that focus on psychoeducation, cognitive restructuring, behavioural techniques, exposure therapy, and stress management. In the perinatal context, standard components of CBT can include integration of planning and support for the postpartum needs whilst the patient receives treatment in the antenatal period. CBT can be delivered in individual or group formats, either in-person or remotely (with varying levels of therapist’s assistance).
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
Cognitive Behavioural Therapy can be delivered by healthcare professionals (e.g. psychologists, psychiatrists, or mental health nurses) who have undergone training to support its delivery. CBT can be delivered to patients weekly or fortnightly, typically over 5-20 sessions.
Technology Support
Cognitive Behavioural Therapy can be delivered without access to technology but access to video platforms for remote delivery can be useful as is access to methods of recording sessions for supervision.
Administrative Support
Cognitive Behavioural Therapy (CBT) is typically delivered weekly or fortnightly, typically over 5-20 sessions, with each session lasting about 30-60 minutes. Face-to-face therapy sessions can be held in several settings including community mental health centres, outpatient clinic settings, hospitals, and schools. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.
Financial Support
Scottish Government/NES Psychology routinely funds training programmes in CBT and supervisor training. Training is available from other organisations at a cost.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
