by Dr Tom Price, Clinical Psychologist based at the Maudsley Hospital in South London
Setting the scene
In 2016, I was working as an assistant psychologist in an Oxfordshire eating disorders service. I had met clients with anorexia nervosa who described themselves as fixed in their thinking, preferring predictability and order, whilst generally struggling to multitask, feeling quite threatened by spontaneity and the prospect of change. Some talked about needing to focus on the detail, often at the expense of ‘the bigger picture’, even though this was contributing to feeling stuck. Importantly, these ‘thinking styles’ appeared to be tightening the grip of the eating disorder and contributing to impairment in daily life.
I came across a book called ‘Cognitive Remediation Therapy (CRT) for Eating and Weight Disorders’, written by Professor Kate Tchanturia, and was introduced to the potential benefits of ‘practicing thinking skills’ (as an add on therapy) to improve the social, emotional, and cognitive health of those with anorexia nervosa.
What are thinking skills?
‘Thinking skills’ are skills (like paying attention, organising, analysing information, and remembering) we use to process information, make and sustain social connections, and create new ideas and goals for the future. They also help us to look back on past experiences, learn and move forward. We use our thinking skills when trying to make sense of our day to day, to solve problems, make decisions, overcome challenges and evaluate our progress. Everyone has thinking skills. They start developing from an early age and are often supported to grow by the people around us.
Soon after, I moved into an assistant post working with a research group exploring the feasibility of delivering computer assisted CRT in NHS community services. The trial was working with people experiencing a ‘first episode of psychosis’ – another group of people whose interpersonal relationships, employment and physical health are impacted by ‘thinking skills’ impairments that often start long before seeking help from mental health services.
My CRT training was an intensive small group course focussing on the theoretical background of CRT, assessment and formulation using a model that incorporates ‘metacognitive thinking skills’ (or the ability to think about our thinking). This course introduced me to wider clinical and service-related considerations in delivering CRT, and encouraged attendees to consider their ‘therapist competencies’ (i.e., what are we bringing to CRT? How to adopt a motivational stance; how to link massed practice and ‘thinking skills tasks’ to real world goals). The course included training in CIRCuiTS and how to deliver CRT. Of course, I was lucky enough to be embedded within a research group made up of many high skilled CRT practitioners. Where access to an experienced CR trained supervisor is not feasible, I would encourage people to get in touch with the CIRCuiTS team for advice on supervision.
CRT in practice
I delivered CIRCuiTS across four NHS early intervention services, working with over 30 young people experiencing a first episode of psychosis. People enjoyed working through interactive ‘thinking skills tasks’ and linking their progress on the platform to short- and medium-term goals they had set in the ‘real world’. The therapy is flexible and can be tailored to both individual and group formats.
My favourite CIRCuiTS Task?
I enjoyed using the ‘on the train’ task, alongside other planning tasks linked to bus or train timetables, with clients. Many of the young people I worked with were experiencing barriers to accessing the community. Others described low confidence around ‘going out’ due to fear of getting lost, difficulty planning routes to new places or generating ideas of ‘where to go’. These tasks enabled clients to practice important ‘thinking skills’ in a safe and supportive environment, whilst developing behavioural experiments and plans with their therapist to put the ‘virtual’ into practice. Progress towards these goals was reviewed regularly, either with me or by looking to their progress log and other learning resources in the CIRCuiTS Library.
Looking to the future
I hope that mental health professionals continue to upskill themselves, building confidence to notice and collaboratively formulate the possible impact of thinking skills (and difficulties related to cognitive processing) on the lives of people seeking their support.
We know that many mental health problems have neurodevelopmental underpinnings. Training effective thinking skills in childhood or early adolescence (as part of early intervention initiatives) may reduce the odds of developing mental health problems linked to cognitive dysfunction. For others now living with mental health problems, I hope sensitivity to possible cognitive problems will support people to move towards personally meaningful goals and their own definitions of recovery.
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