CBT workbooks: more than just manuals?
Cognitive-behavioural therapy (CBT) is the most intensively researched mental health intervention.
A meta-review identified 494 reviews, representing over 220,000 participants, concluding that CBT is beneficial across conditions, populations, and contexts (Fordham et al., 2021).
Most CBT research uses manuals: standardised guidelines about the theory, sequencing, content, and procedures of sessions (Marshall, 2009). However, outside the sphere of research, some practitioners feel manuals are restrictive and diminish the importance of professional expertise (Shedler, 2018). There is a complex question of how far practitioners should adhere to pre-tested and evidence-based guidelines and how far they should adapt to situational demands and rely on professional judgment (Fox, 2003).
A close cousin of the manual is the workbook. There is no formal definition of ‘workbook’ as there is no peer-reviewed research on how they are used. A working definition is that workbooks offer materials and advice to support interventions without prescribing an approach. To address this research gap, I conducted surveys and interviews to explore how practitioners use a popular CBT workbook, Think Good – Feel Good (TGFG), and how TGFG supports therapeutic outcomes (Stallard, 2018).
When do practitioners use Think Good Feel Good?
When deciding whether to use TGFG, practitioners consider four key factors.
Type of difficulty
96% use it for ‘anxiety’, 64% for ‘challenging behaviour’, and 61% for ‘low mood’. This supports the well-evidenced finding that CBT is most effective for anxiety (Sigurvinsdóttir et al., 2020). The high rate of ‘challenging behaviour’ is more difficult to explain as CBT is typically used with internalising mental health difficulties. It could be that since most respondents were EPs, this finding reflects the priorities of schools seeking support for children with ‘challenging behaviour’. Surface level ‘behaviours’ are likely influenced by underlying wellbeing and systemic factors.
Children’s understanding and self-awareness
A judgment based on developmental maturity rather than chronological age.
Motivation
Participants were concerned that schools or parents might push children into interventions they would rather not attend. Motivation could be enhanced through working collaboratively, being transparent and honest, building rapport, and experiencing the novelty of having space and time to reflect on mental health concerns.
Quality of systemic support from educational settings and families
Schools must facilitate therapeutic sessions by agreeing for EPs to use their time for extended individual work and providing confidential spaces. This was often seen as a limiting factor, particularly in an increasingly traded context. Supportive systems are also important for embedding and maintaining change in the long-term, once therapeutic sessions finish.
Practitioners use Think Good Feel Good more flexibly when they’re more confident
Flexibility encompassed two main approaches. First, practitioners adapted the resources provided in TGFG. They did this by personalising content to suit children’s interests and simplifying content to make it more accessible and reduce language demands. A few participants highlighted that generic resources could be useful because they feel less personal and therefore easier to discuss.
The second form of flexibility referred to combining TGFG with other therapeutic approaches, illustrated by the phrases “dip in and out” and “one strand among other strands” – taking what works from TGFG and leaving what does not. This pragmatic approach could undermine any research evidence supporting the approach. From another perspective, such an approach to practice is in the spirit of the applied scientist, testing and combining different approaches based on what works for people in unique circumstances (Barker et al., 2016).
TGFG is used by practitioners with varying levels of professional experience, with most survey respondents having 11+ years’ experience. Many practitioners felt that because TGFG was evidence-based and recommended by colleagues, the workbook gave them “permission to be creative”, increasing their confidence in their own judgment.
Interestingly more experience was associated both with being more likely to be CBT-trained (rather than self-taught) and with being less likely to read directly from the workbook. Experience, training, and self-confidence were interconnected.
Why does Think Good Feel Good support therapeutic outcomes?
My findings suggest that TGFG supports practitioners both practically and emotionally. Around 80% of practitioners use TGFG as a planning aide, supporting them in terms of efficiency (reminding them what to cover and saving time when preparing an intervention), understanding (education or revision of concepts), and self-confidence (reassurance they are doing the ‘right’ (evidence-based) thing).
Nearly 80% of practitioners use TGFG worksheets directly during therapeutic sessions. By far the most valued resources are those with a cognitive focus rather than those with emotional or behavioural foci. The six cognition-focussed TGFG chapters were the six most used and 9/10 of the most-used worksheets came from these chapters. This could reflect that cognitive insight is at the heart of achieving change through CBT (Kaplan et al., 1995). It could also reflect that cognitive concepts are difficult to explain and hard to understand (Verduyn, 2000), so physical resources make ideas tangible and concrete.
In addition to explaining content, worksheets could build therapeutic alliance in three ways:
- Worksheets have boundaries (e.g. questions to answer) so can be completed, leading to a sense of achievement which could enhance motivation and focus.
- Writing things down means they can be seen by practitioner and child. This could aid transparent communication and be validating for children if they see something that reflects, or enhances, their self-understanding. If something inaccurate were written, it could be edited, giving children control and enabling them to feel heard.
- Since worksheets are external stimuli to which practitioners and children can jointly pay attention, they contain the emotional intensity of talking about difficult personal experiences.
Key takeaways for Think Good Feel Good users
- Consider how to negotiate referrals effectively: judge the nature of children’s difficulty, understanding, motivation, and the extent of systemic support during and after the intervention.
- Read TGFG as a revision tool for core CBT concepts and use it as a planning aide to make running interventions more efficient.
- Reflect on the added value brought by supplementary resources (i.e. worksheets) and look to maximise their implementation in therapeutic interactions.
- Aim to strike a balance between building therapeutic alliance, fostering systemic support, and completing ‘content’ such as worksheets during interventions.
- Consider whether parents or school staff might use aspects of TGFG to embed learning.
- Consider your own and others’ training needs – reading TGFG is not equivalent to formal CBT training and does not provide systemic support to practitioners such as supervision.
James’ thesis is available open access from UCL.
James’ webinar with EP Reachout – Adolescent’s views on CBT, what works and what doesn’t
References
Barker, C., Pistrang, N., & Elliott, R. R. (2016). Research methods in clinical psychology: An introduction for students and practitioners (3rd ed.). Wiley-Blackwell.
Fordham, B., Sugavanam, T., Edwards, K., Stallard, P., Howard, R., das Nair, R., Copsey, B., Lee, H., Howick, J., Hemming, K., & Lamb, S. E. (2021). The evidence for cognitive behavioural therapy in any condition, population or context: A meta-review of systematic reviews and panoramic meta-analysis. Psychological Medicine, 51(1), 21–29. https://doi.org/10.1017/S0033291720005292
Fox, M. (2003). Opening Pandora’s box: Evidence-based practice for educational psychologists. Educational Psychology in Practice, 19(2), 91–102. https://doi.org/10.1080/02667360303233
Kaplan, C. A., Thompson, A. E., & Searson, S. M. (1995). Cognitive behaviour therapy in children and adolescents. Archives of Disease in Childhood, 73(5), 472–475. https://doi.org/10.1136/adc.73.5.472
Marshall, W. L. (2009). Manualization: A blessing or a curse? Journal of Sexual Aggression, 15(2), 109–120. https://doi.org/10.1080/13552600902907320
Shedler, J. (2018). Where is the evidence for “evidence-based” therapy? Psychiatric Clinics of North America, 41(2), 319–329. https://doi.org/10.1016/j.psc.2018.02.001
Sigurvinsdóttir, A. L., Jensínudóttir, K. B., Baldvinsdóttir, K. D., Smárason, O., & Skarphedinsson, G. (2020). Effectiveness of cognitive behavioral therapy (CBT) for child and adolescent anxiety disorders across different CBT modalities and comparisons: A systematic review and meta-analysis. Nordic Journal of Psychiatry, 74(3), 168–180. https://doi.org/10.1080/08039488.2019.1686653
Stallard, P. (2018). Think good – feel good: A cognitive behavioural therapy workbook for children and young people (2nd ed.). John Wiley & Sons, Ltd.
Verduyn, C. (2000). Cognitive behaviour therapy in childhood depression. Child Psychology and Psychiatry Review, 5(4), 176–180. https://doi.org/10.1017/s1360641700002379
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