The value of cognitive behavioural therapy

Cognitive behavioural therapy is a valuable tool in getting employees back to work. Edmund Tirbutt assesses what is available

Brain scan

With stress and mental issues amongst of the most debilitating and expensive conditions facing both employees and employers, income protection insurers are increasingly positioning themselves on their ability to tackle stress, anxiety and depression via cognitive behavioural therapy (CBT).

The subject of CBT, which uses psychotherapy to address dysfunctional emotions, behaviours and conditions through a goal-oriented process, is a hot topic amongst insurer rehabilitation professions, who invariably point to unique selling points. But how do offerings on the market compare and how effective is it in getting staff back to their posts?

Whereas most insurers use both NHS and private therapists, Legal & General and Aviva only use private ones. The former has an exclusive tie-up with CBT Services and the latter generally uses dedicated partners The Priory and HCML. Friends Life is also unusual in emphasising its use of CBT to help with physical conditions.

Declan White, head of group protection strategy and marketing at Friends Life, says: “We use experts who may use this technique for treating musculoskeletal conditions as well. For example, we would use a physiotherapist, who not only helps someone with their bad back, but also helps them using CBT to change the way they think and feel about their condition and the restrictions that it imposes on them in their daily life.”

CBT is recommended for stress-related problems by the National Institute for Health and Clinical Excellence (NICE), and some of the success rates volunteered by insurers are certainly impressive. Aviva reports “a successful outcome” in 96 per cent of cases and Legal & General reports that 73 per cent of people who have CBT get back to work by the end of the deferred period. Indeed, Vanessa Sallows, underwriting and benefits director for group protection at Legal & General, says that she has sometimes been told that presentations she has done on her CBT model “have clinched the deal.”

Despite these impressive figures, specialist intermediaries tend not to dwell unduly on CBT when making scheme recommendations. They commonly say they pay some attention to the subject but that it is never a deciding factor.

Simon Derby, director of i2 Healthcare, says: “CBT is one of many tools in the box provided by insurers but is not a deal breaker. The problem is that all providers have their own unique selling points on claims services generally and CBT is only one consideration here, although it could have some kind of sway if there was little to choose between insurers once the basics of cost, cover and service have been ticked.”

Gallagher Employee Benefits doesn’t recommend a provider without checking that it has an acceptable CBT programme in place but admits that if a provider really stood out in this area it would be unlikely to make much difference to its recommendations. IHC also wouldn’t set much store on a provider actually excelling at CBT but if it didn’t offer the treatment at all it would be a question mark that was highlighted to the client.

But Portus Consulting and Lorica Employee Benefits pay more attention to the subject, highlighting its importance in the light of rising stress-related claims. Portus looks at the CBT capabilities of all insurers before narrowing down its choices to a shortlist of only two or three while Lorica tends to assess CBT capabilities once it has already come up with a short list of two or three insurers.

Sandra Hall, senior consultant at Lorica Employee Benefits, says: “We would look at how income protection insurers assess whether someone is appropriate for CBT, how they deliver it and how it fits in with any CBT cover on private medical insurance (PMI). We will have a higher focus if the client has a significant spend on mental health, either through PMI or group income protection claims. With some clients we have made specific arrangements as to how CBT is accessed via income protection or PMI.”

Healthcare experts, although volunteering considerable support for CBT, invariably emphasise that it is by no means suitable for everyone. In particular, it may not work for personality disorders, for psychosis like schizophrenia or bipolar conditions, if someone is not motivated to change or if other factors get in the way, such as a mistrust of the income protection provider.

Dr. Penny O’Nions, principal of The Onion Group, is a qualified GP as well as being an independent financial adviser (IFA). She says “I certainly think CBT has a place and is a useful tool for getting people back to work. Like a lot of therapies, if it works for you it can be very good but if it doesn’t it can have its problems. If you are the type of person who responds to hypnotherapy then it can work very well, as it is based on the idea that a condition can be overcome by altering your mental state.”

Some healthcare experts also flag up the fact that the standard of CBT offered via employee assistance programmes (EAPs) can be very different to that offered by income protection rehabilitation services. EAPs tend to restrict CBT to around half a dozen sessions (whereas NICE recommends up to 20 sessions) and to focus on preventing people going off work as opposed to rehabilitating them back into the workplace.

Pamela Gellatly, chief executive of Healthcare RM, says: “Our experience of working with EAPs is that they tend to use a very low level of CBT practitioner, which is fine for minor anxiety and depression but certainly won’t resolve all problems. For group income protection you normally get a higher level of CBT practitioner.”

But EAP providers also have their side of the story to tell. Amian EAP, for example, points out that around half its CBT therapists are higher-level ones and half lower-level ones and that, although users are typically restricted to six to eight sessions of CBT, some contracts allow them to apply for more.

Whether offered via an EAP or via an income protection rehabilitation department, some experts also stress that CBT is in danger of becoming outdated by changes in the attitudes of the more progressive employers and of the medical community as a whole.

Oliver Gray, managing director of energiseYou, says: “New school type businesses will very rarely get to the point of needing CBT because they take a very proactive approach to staff welfare and spot problems before they arise. If a company needs CBT the manager probably hasn’t done their job and, in my opinion, CBT is very old hat. Its essence is that your thinking ultimately determines your actions but if a company is developing a positive culture it will be achieving this anyway.”

Adrian Lock, senior consultant at Roffey Park Institute, says: “CBT has proved one of the forms of counselling and psychotherapy that has produced the evidence that Nice looks for. But the NHS also acknowledges that something beyond what CBT can offer is needed, such as a holistic approach which incorporates people’s search for a sense of meaning and purpose, and even answers to more spiritual questions. In my own experience going beyond the questions that CBT would help answer is needed for long-term health and wellbeing.”

WHAT IS CBT?

Cognitive behavioural therapy, which typically involves between eight and 20 hour long sessions within a six week to six month period, is a talking therapy which can help with a wide range of mental health difficulties by challenging negative beliefs. It is based on the understanding that what people think can have a significant impact on how they behave and feel.

People can feel very differently about themselves when they are mentally distressed, and their thoughts can become extreme and unhelpful. But CBT practitioners can often instigate a major improvement in how clients feel and live by helping them to change their thinking and behaviour.

The two parties work together to identify and understand problems in terms of the relationship between thoughts, feelings and behaviour. They talk about how the client thinks about themselves, the world and other people, and about how what they do affects their thoughts and feelings. Problems are broken down into smaller parts like situations, thoughts, emotions, physical feelings and actions. This makes it easier to see how the parts are connected and how they affect the individual.

Unlike some other forms of therapy, little time is spent analysing early-life experiences. Instead the emphasis is on targeting problems in the here and now. The therapist and client develop a shared view of the individual’s problems and this leads to the identification of personalised therapy strategies and goals, which are subject to continuous monitoring and evaluation. The overall aim is for the individual to attribute improvement in their problems to their own efforts.

But one of the main barriers to usage is that referrals for CBT on the NHS are hard to get and can involve lengthy waiting lists. There has also traditionally been a lack of suitably skilled practitioners for private treatment. Accessibility has, however, improved somewhat since the government invested in training over 3,600 new CBT therapists following a report by Lord Layard in 2006.

Online CBT formats are also becoming increasingly available, with two having been approved for use by the NHS: FearFighter for people with phobias and panic attacks and Beating the Blues for people with mild to moderate depression.