Introduction
Functional syndromes such as chronic fatigue syndrome (CFS, sometimes known as ME or CFS/ME) and irritable bowel syndrome (IBS) are illnesses characterized more by symptoms, suffering, and disability than by disease specific, demonstrable physiological abnormalities. CFS is characterized by disabling fatigue that has been present for at least 6 months, whilst the core symptoms of IBS are abdominal pain, diarrhoea, and/or constipation.
Cognitive behaviour therapy (CBT) appears to be an effective therapy for both IBS and CFS (e.g. White et al., Reference White, Goldsmith, Johnson, Potts, Walwyn and Decesare2011; Kennedy et al., Reference Kennedy, Jones, Darnley, Seed, Wessely and Chalder2005) and is recommended in the NICE (2007) CFS/ME guidelines. Evidence from a recent meta-analysis suggests that effect sizes for CBT in CFS are lower in primary care settings and with fewer sessions (Castell, Kazantzis and Moss-Morris, Reference Castell, Kazantzis and Moss-Morris2011). CBT is also an empirically-validated intervention for chronic fatigue (CF) that does not meet the criteria for CFS/ME (e.g. Ridsdale et al., Reference Ridsdale, Godfrey, Chalder, Seed, King and Wallace2001) including CF that occurs in the context of other health conditions such as multiple sclerosis (e.g. Van Kessel et al., Reference van Kessel, Moss-Morris, Willoughby, Chalder, Johnson and Robinson2008). Lower intensity versions of CBT such as guided self-management interventions have been shown to be effective for both CF and IBS (e.g. Moss-Morris, McAlpine, Didsbury and Spence, Reference Moss-Morris, McAlpine, Didsbury and Spence2010).
CBT for these conditions differs from CBT applied to mental health conditions such as depression and anxiety. The focus is on cognitions and behaviours that may be maintaining disability and symptoms rather than mood per se. Engagement of patients in a talking therapy when they present with physical symptoms requires a specific skills set. However, there are no competences for the delivery of such interventions for these patient groups. Low and high-intensity CB interventions for CF, CFS/ME and IBS are increasingly used outside of specialist settings; for example, they are being introduced to Improving Access to Psychological Therapies (IAPT) services in parts of the UK. High intensity therapies usually require more sessions and are based on individual formulations of the presenting problems. Low intensity interventions tend to follow more structured manualized therapy, often in a self-help format, with a few sessions of additional support provided by a therapist. In order to facilitate training, delivery and supervision, we developed a set of competences for both high and low-intensity forms of CB intervention. This report describes the development of these competences. The format was based on that used for “problem specific” CBT competences in the Roth and Pilling (Reference Roth and Pilling2007) framework. These new specific competences for CFS, CFS/ME and IBS are designed to be used in conjunction with the existing “basic” and “specific” CBT competences, and generic therapeutic competences and metacompetences (Roth and Pilling, Reference Roth and Pilling2007).
Method
Initial drafts of the competences were written by KR, following discussion with the other authors. These drafts drew on published materials, including descriptions of cognitive behavioural treatment provided in clinical model papers (e.g. Surawy, Hackmann, Hawton and Sharpe, Reference Surawy, Hackmann, Hawton and Sharpe1995), materials from randomized controlled trials, and the therapist manual by Burgess and Chalder (www.pacetrial.org/docs/cbt-therapist-manual.pdf) used in the PACE trial (White et al., Reference White, Goldsmith, Johnson, Potts, Walwyn and Decesare2011). KR has over 12 years’ experience of providing and evaluating CBT with CFS/ME and researching medically unexplained symptoms. TC has been involved in the development of new CB interventions for CF, CFS/ME and IBS (e.g. Wessley, David, Butler and Chalder, Reference Wessley, David, Butler and Chalder1989; Kennedy et al., Reference Kennedy, Jones, Darnley, Seed, Wessely and Chalder2005) and the evaluation of these approaches for over 20 years. RMM also has many years’ experience of developing and evaluating CB interventions for long term conditions including IBS (e.g. Moss-Morris et al., Reference Moss-Morris, McAlpine, Didsbury and Spence2010). JW has provided treatments for CFS/ME and CF in specialist and primary settings and was involved in the development of the low-intensity materials.
The low-intensity competences were designed to be used by therapists providing a low-intensity intervention in conjunction with written materials for patients. Two booklets about chronic fatigue had been developed as part of the IAPT Long-term Conditions and Medically Unexplained Conditions Pathfinder project based at Southwark Psychological Therapies Service (South London and Maudsley NHS Foundation Hospital Trust) and Mind in Bexley. These low-intensity materials were developed by JW and TC in conjunction with staff from a specialist CFS Service (South London and Maudsley NHS Foundation Hospital Trust). The content drew on material in Coping with Chronic Fatigue (Chalder, Reference Chalder2003) and Overcoming Chronic Fatigue (Burgess and Chalder, Reference Burgess and Chalder2005). It is intended that these booklets will be made available to other services. Alternatively, Coping with Chronic Fatigue could be used. The low-intensity IBS guide was Managing your IBS Symptoms: a practical approach by Moss-Morris and Didsbury (2007). This unpublished patient guide had been used in a primary care trial (Moss-Morris et al., Reference Moss-Morris, McAlpine, Didsbury and Spence2010) and had drawn on the CB intervention developed in an earlier trial (Kennedy et al., Reference Kennedy, Jones, Darnley, Seed, Wessely and Chalder2005).
The initial drafts of the competences were sent out for consultation to CBT therapists and clinical psychologists who had experience of providing CBT for CF, CFS/ME and/or IBS in primary care or specialist services. Therapists providing low intensity intervention in the local IAPT service (Southwark Psychological Therapies Service) were also asked for feedback. The reviewers are listed in the acknowledgements section. The final versions of the competences associated are available online as supplementary material in the table of contents for this issue: http://journals.cambridge.org/jid_BCP
Results
All of the experienced CBT therapists and clinical psychologists endorsed the competences as generally appropriate and suggested minor amendments. These suggestions were incorporated into the final set of competences. The therapists providing low intensity interventions also indicated that the competences were broadly appropriate, with minor suggestions that were also included (e.g. emphasizing the ability to express empathy regarding any previous lack of understanding from others). Some of the therapists providing low-intensity interventions indicated that the competences were helpful in highlighting areas in which they felt competent and others in which they felt in need of further training or skills development (e.g. basic knowledge about other forms of validated treatments).
Discussion
As cognitive behavioural approaches for CF, CFS and IBS are now being provided more widely outside of specialist settings, it becomes increasingly important for competences in providing these interventions to be developed. The competences described here, and also available online as supplementary material, were found to be acceptable by CBT therapists and clinical psychologists who were experienced in providing cognitive behavioural interventions for these conditions. Feedback indicated that they were perceived as useful by therapists providing low-intensity interventions as a means of highlighting areas that were in need of further skills development. This feedback is being used to inform training sessions provided in IAPT services.
After these present competences were developed, a UK Expert Reference Group began developing a national competences framework for psychological interventions with people with functional somatic symptoms. The new competences framework will be published in due course on the University College London (UCL) CORE website, along with the other suites of competences frameworks.
Acknowledgements
KR acknowledges support provided by funding awarded to South London and Maudsley NHS Foundation Trust and Mind in Bexley from the Improving Access to Psychological Therapies LTC/MUS Pathfinder Project. TC and RMM acknowledge support from the National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London. We are very grateful to the therapists who provided feedback on the draft competences, including; Barbara Bowman, Mary Burgess, Jack Cahill, Zoe Clyde, Simon Darnley, Antonia Dittner, Jon Freeman, Chloe Gerskowitch, Philip Kinsella, Anne-Marie Lister, Katherine MacDonald, Chris Merritt, Patrishia Paulraj, Suzanne Roche, Diana Sanders and Christina Surawy.
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