II. GENERAL INTRODUCTION
2. Cognitive-behavioural therapy and brain disorders
2.1 Cognitive-Behavioural therapy models
Cognitive-behavioural therapy (CBT) is a type of psychotherapy that has its origins in behavioural therapy. The latter is based on the empirical approach of operant conditioning, which considers that a behaviour is more likely to occur if the same behaviour (or a similar one) was reinforced in the past (Fontaine & Fontaine, 2011). Reinforcers can be primary (such as food or sex) or generalized (such as money or social attention). In the context of pure behavioural therapy (Skinner, 1965), emotions are conceived as hidden behaviours, and therefore considered to be governed by similar ‘rules’ as ‘external’ behaviour. However,
though pure behaviourist models are still used in therapeutic practice, subsequent theories considering internal events (such as emotions and cognitions) as distinct phenomena that do not follow strict stimulus-response relations gained considerable importance in the second half of the XXth century (Fontaine & Fontaine, 2011).
Modern CBT theories are grounded in early cognitive models of depression proposed by Beck (A. T. Beck, Rush, Shaw, & Emery, 1979). A core feature in these theories is the notion that emotions arise in a given context and are influenced by cognitions (thoughts and beliefs about the situation), behaviour and physical reactions. This relationship is not unidirectional as emotions also influence physical reactions and behaviour (attitudes), with repercussions in the environment (for example an interlocutor may be verbally aggressed, or the physical environment of the angry person may be changed due to isolation). The approach to understand this complex interrelationship is termed functional analysis, and is a key component of cognitive-behavioural treatments. In addition, CBT emphasizes therapeutic relationship as an important part of the treatment. Treatments differ depending on the importance given to each component of the functional analysis and to the attitude toward it.
CBT has gained importance in the scientific community due to its straightforward nature, experimental character and liability to study effects of intervention (McMain, Newman, Segal, & DeRubeis, 2015). Treatments are usually adapted to very specific goals and there is an attempt to quantify progress and/or treatment success. Several randomized controlled trials assessed the effects of cognitive-behavioural therapy on different psychopathological parameters. These studies show that CBT effectively reduces anxiety and depression in different populations (children, adult and elderly) (Hundt, Mignogna, Underhill,
& Cully, 2013; Rooksby, Elouafkaoui, Humphris, Clarkson, & Freeman, 2015; Watts, Turnell, Kladnitski, Newby, & Andrews, 2014) and this approach is considered a treatment of choice for anxiety (Hofmann & Smits, 2008). It is also employed in the treatment of personality or psychotic disorders (Gratz, Bardeen, Levy, Dixon-Gordon, & Tull, 2015; Li et al., 2014) and to facilitate coping in several chronic diseases such as diabetes, coronary disease, tumours or chronic pain (Dowd et al., 2015; Eccleston, Palermo, de, et al., 2012;
Eccleston, Palermo, Fisher, & Law, 2012; Mann et al., 2012). Due to its limited length and proven effectiveness, the popularity of CBT also extends to treatment targeting specific emotional conditions such as anger regulation (R. Beck & Fernandez, 1998).
2.2 Cognitive-behavioural therapy for patients with brain disorders
CBT for patients with brain disorders has gained interest in the last decade for several reasons (Coetzer, 2009). First, emotional and behavioural changes are increasingly recognized as major consequences of brain disorders, while previously attention had predominantly been directed to cognitive and physical consequences. In addition, CBT has been scientifically proven effective in populations with different psychiatric conditions, and recent studies with neurological patients have shown promising outcomes. Qualitative observations made by clinicians in their daily practice also suggest that this type of intervention should be encouraged (Judd & Wilson, 2005). Indeed, the goal-directed and structured nature of CBT makes it particularly suitable for patients with various forms of brain injury (Coetzer, 2009;
Kangas & McDonald, 2011). Working on concrete examples of current life situations and application of specific strategies such as visual support (schemes, written handouts…) and role-playing make it accessible to patients with attention, executive or memory deficits.
Despite being naturally adaptive to brain disorders, CBT given to this population needs particular care regarding delivery methods. For instance, therapists should ensure a distraction-free environment, constantly summarize contents of discussions, shorten sessions and be very directive in order to compensate for eventual memory problems and executive dysfunction (Coetzer, 2009).
CBT has proven its effectiveness for the reduction of anxiety and improvement of mood following brain injury, the promotion of adaptive coping skills and attenuation of symptoms of post-traumatic stress disorders (Anson & Ponsford, 2006b; Waldron, Casserly,
& O'Sullivan, 2013). For instance, Mitchell and collaborators (2009) reported greater reduction of post-stroke depression symptoms in patients who had participated in a CBT program compared to those receiving treatment as usual (appointments with the rehabilitation physician or general physician as well as antidepressants if used). Anson and Ponsford (2006a) observed better coping skills after a CBT group intervention for patients with traumatic brain injury. In subsequent work these authors described that greater self-awareness, less severe impairment and greater anxiety prior to intervention were predictors of better outcome (Anson & Ponsford, 2006b). On the other hand, effects of specific CBT programs targeting important neurobehavioural issues such as social skills and anger management have been examined to a lesser extent (Hart, Brockway, Fann, Maiuro, & Vaccaro, 2014;
McDonald et al., 2008; Medd & Tate, 2000; Walker et al., 2010).
Unfortunately, despite positive outcomes, evidence-based reviews indicate that methodological quality of trials in the field is limited. For instance, Catellani and collaborators (2010) and Doering and Exner (2011) reviewed levels of evidence of studies focusing on CBT for patients with acquired brain injury and proposed clinical guidelines.
They used a rating system based on the guidelines of the European Federation of Neurological Societies (Cappa et al., 2005), which had previously been used in a review concerning cognitive rehabilitation programs (K. D. Cicerone, Azulay, & Trott, 2009). According to this rating system a well-designed randomized controlled trial is rated “class 1 evidence”. Case-control studies or non-randomized Case-controlled studies are rated as “class 2 evidence”, while case series or case reports are rated “class 3 evidence”. The presence of at least one class 1 study with eventual support of class 2 studies is necessary to consider intervention as specifically recommended (practice standard) for people with emotional and behavioural problems related to brain disorders. Probable effectiveness (practice guidelines) is defined when at least one class 1 study with methodological limitations or several class 2 studies are available, whereas a poor degree of evidence (practice option) is considered to be present when there are conflicting results of class 2 and class 3 studies. Catellani and collaborators (2010) found 13 studies using CBT for patients with acquired brain injury (one class 1, three class 2 and nine class 3). The only class 1 study did not report positive outcomes and class 2 studies reported mixed results. As a consequence, CBT for patients with brain injury was considered a practice option (similar conclusions were reached for neuropsychological rehabilitation programs in the review carried out by Cicerone, 2011). Hence, results of these reviews reflect the paucity of studies in the field, particularly compared to programs focusing on cognitive issues, as well as a poor degree of controllability. This is in part related to the early stage of research focusing on CBT for patients with brain disorders and to the numerous practical concerns in designing a well-controlled-study in psychotherapy.
The study rated class 1 evidence in the review by Catellani and colleagues (2010) was a randomized controlled trial which compared the effects of a CBT intervention on post-stroke depressive symptoms to a control program in which therapists provided attention and support, but did not use any CBT technique, and to a third group without any intervention (Lincoln & Flannaghan, 2003). Their CBT program began between one to six months post-injury and was administered individually once-a-week for 10 weeks. Although there was an overall decrease in depressive symptoms over time, no differences in improvement were observed between groups. This study was performed in a post-acute stage of stroke, when
cognitive consequences such as slow processing speed and decreased self-activation may be confounded with depression. Hence, spontaneous recovery of these symptoms is expected and may be unrelated to emotional adjustment. In addition, a strong limitation of the study, which was emphasized by the authors is that treatment was delivered at home. This implies that explicit commitment to therapy was not necessarily required, which could potentially explain the absence of CBT effects due to lack of ‘ understanding, willingness and belief in therapy’
(Lincoln & Flannaghan, 2003) . In turn, the delivery method avoided drop-outs, which can be a major obstacle in clinical trials, particularly in the control conditions.
Choosing an adequate control condition is a major challenge in psychotherapy trials (Hart, Fann, & Novack, 2008). It requires a balance between ethical issues, acceptability to participants, credibility of intervention, management of resources (e.g. therapist availability) and above all drop-out prevention. The following conditions have been employed in different studies: no treatment at all for the control group, comparison to ‘usual care’ (also termed
‘treatment as usual’ where patients receive usual care such as physical therapy, neuropsychological rehabilitation and occupational therapy but no psychotherapy is given), wait list-control (in which control participants wait to receive the active intervention) or
‘placebo analogue’. The latter consists of administering an intervention with resemblance regarding the format, but which is not useful to treat the condition. It has more resemblance with medication trials, but leads to an increased rate of drop-outs since intervention may not be acceptable or credible to participants or therapists (Hart et al., 2008). Other solutions include dose-control treatment (for example providing fewer sessions) or dismantling designs (changing the order of sessions), but in these large samples are required in order to achieve satisfactory statistical power.
In sum, even though CBT for patients with brain disorders may be a promising approach to improve emotion regulation in this population, the quantity and quality of current studies so far are insufficient to provide strong scientific evidence for its recommendation in clinical practice.
2.3 Cognitive-behavioural therapy for caregivers
Intervention for caregivers of patients with brain disorders intend to reduce burden and increase well-being, but also to improve the quality of care by providing information on the
disease and on patients’ particular needs (Losada Baltar & Montorio Cerrato, 2005). CBT may support the caregiver in understanding the impact their relative’s brain disorder has on their own life and in identifying personal beliefs about the disease. It helps in the clarification of their role as caregiver and encourages the involvement of other family members in the care (Dunkin & Anderson-Hanley, 1998; Vernooij-Dassen, Draskovic, McCleery, & Downs, 2011). These topics are of particular importance since social support and learning adaptive coping strategies are associated with decreased psychological distress in caregivers of patients with traumatic brain injury (Ergh et al., 2002; Stejskal, 2012). Several interventions for caregivers of patients with acquired brain injury (patients with traumatic brain injury, stroke or brain tumours) focused on increasing caregiver’s knowledge and building skills for dealing with the patient, but much fewer focused on emotional adjustment (Ramkumar & Elliott, 2010). Nonetheless, results of the latter studies suggest a decrease in caregiver distress and increased abilities to cope with problems related with caregiving. They also show a positive impact on symptoms of depression. For instance, in a randomized-controlled trial for caregivers of patients with traumatic brain injury, depressive symptoms significantly decreased following a CBT intervention whereas they increased in the control group (P. A.
Rivera, Elliott, Berry, & Grant, 2008). Interestingly, care-recipients of this study also presented a significant decrease in depressive symptoms, suggesting that interventions targeting caregivers also have an impact on emotional disorders of cared-for patients. In line with this, a systematic review of psychological interventions for caregivers of patients with dementia (Selwood, Johnston, Katona, Lyketsos, & Livingston, 2007) showed that CBT is not only effective in improving psychological well-being of caregivers, but may also reduce neurobehavioural symptoms of cared-for patients.