Paul Salkovskis





Hoarding: a question of value

Hoarding has become a focus of considerable interest recently particularly with it having been categorised as a distinct disorder in DSM 5. Apart from the intense and pervasive misery associated with the problem, it is now also clear that hoarding has important personal and public health consequences. 

In this workshop we describe how hoarding, defined as the acquisition and retention of possessions in ways which mean that significant amounts of living space are not able to be used, is a "final common pathway” behavioural consequence of several psychological problems. The different cognitive-behavioural pathways leading to excessive accumulation are described along with cross cutting issues such as interpersonal and financial matters. These pathways include but are very definitely not confined to factors associated with OCD. 

It is thus suggested that, rather than merely being a subtype of OCD, hoarding can result from and be maintained by a range of inter-related psychological processes which tend to converge on the issue of perceived value to the self. 
The workshop will describe how to assess those who hoard with regard to their social and physical context, the problems of engagement in treatment and treatment itself both in psychological and practical terms. The way cognitive, behavioural and interpersonal factors are integrated will be described. Strategies for assessment, engagement, cognitive change and routes to behavioural change will all be presented. The importance of working "in vivo” is emphasised and strategies of doing this outlined.

The importance of risk assessment and maintenance  of gains will also be considered. 



CBT for Medically Unexplained Symptoms: combining core strategies and problem specific tactics

In this workshop, Paul will describe the cognitive behavioural theory of health anxiety and how that has been applied to the development and validation of a treatment which evidence suggests is both effective and cost effective, and which can be relatively easily learned by health professionals. The main components of this treatment will be described and illustrated, with the emphasis on the clinical "how to”.

The complex link between health anxiety and problems in general medical settings (both primary and secondary care) will be discussed, and evidence for generalisation to both MUS and LTC evaluated. The adaptations required for the application of the health anxiety treatment in this context will then be outlined, particularly focusing on the fact that anxiety and perception of threat alone will not always account for the maintenance of psychological distress in such problems. A trans-diagnostic model will be detailed which allows the application of a transdiagnsotic CBT approach to therapy. However, it is emphasized that attention to specific issues is also required, so the treatment is in fact a hybrid of transdiagnostic and specific elements. The way such treatment should be conducted, from screening, assessment and formulation and engagement through to more active treatment, behavioural experiments and generalization strategies will be outlined in the context of MUS such as IBS, chronic pain, CFS and so on.

The importance of using an empirically and theoretically grounded transdiagnostic approach as a way of ensuring high quality therapy is thus considered in the context of the need to address the specific issues in symptomatically diverse problems such as chronic pain, Irritable bowel, chronic fatigue and so on. Core elements of treatment include engagement and developing a shared understanding supplemented by "modules” addressing specific aspects of MUS in the later stages of treatment, with behavioural experiments cutting across both aspects of the treatment. Treatment fundamentals and details will be discussed and, where possible, demonstrated.

Key references
Salkovskis, P. M., Warwick, H., & Deale, A. C. (2003). Cognitive-behavioral treatment for severe and persistent health anxiety (hypochondriasis). Brief Treatment and Crisis Intervention, 3(3), 353.

Salkovskis, P. M., Gregory, J. D., Sedgwick-Taylor, A., White, J., Opher, S., & Ólafsdóttir, S. (2016). Extending Cognitive-Behavioural Theory and Therapy to Medically Unexplained Symptoms and Long-Term Physical Conditions: A Hybrid Transdiagnostic/Problem Specific Approach. Behaviour Change, 1-21.

Wattar, U., Sorensen, P., Buemann, I., Birket-Smith, M., Salkovskis, P. M., Albertsen, M., & Strange, S. (2005). Outcome of cognitive-behavioural treatment for health anxiety (hypochondriasis) in a routine clinical setting. Behavioural and Cognitive Psychotherapy, 33(02), 165-175.



Doing the best we can: Principles and practice of bringing better Psychological help to those who need it most

Cognitive-behavioural approaches to health problems continue to evolve according to both evidence based and empirically grounded principles. As CBT is more widely adopted in diverse health care settings, older models of psychotherapy delivery have become increasingly difficult to sustain. To complicate matters further, CBT has widened tremendously in terms of both theory and applications in ways which services, practitioners and service users can find confusing. The key principles and core values which unite diverse approaches to CBT and allow its flexible application are considered in the context of a rapidly changing healthcare landscape. It is proposed that what is needed is a complex blend of public health and prevention, clinical art, clinical science and treatment delivery matched to needs, resources and values. CBT professionals also need to develop and implement better ways of empowering those that they seek to help.