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2.2 CBT and MDT
The purpose of CBT is to affect thoughts, feelings and behavior in a positive
direction, by combining behavioral and cognitive therapy. Individuals learn
to recognize difficult situations and to identify and implement an acceptable
response. There are several different methods and the boundaries are not
precise, but strategies with exercises and home assignments are important
components (Swedish Government and Swedish Association of Local
Authorities and Regions, 2011).
The medical rehabilitation guarantee for CBT implied availability in two
steps. First, a medical evaluation and a structured psychological
assessment should be performed by qualified personnel, resulting in a
diagnosis giving a picture of the syndrome, the personality and the
functioning in relation to work. After an initial assessment, individuals with
mild or moderate mental illness should be offered CBT individually or in
groups. The number of treatment sessions is individualised, but a
treatment sequence should in general contain 10–15 sessions.
MDT has been developed for treating individuals with lasting pain and
relatively severe and complex rehabilitation needs. There is no description
of the exact structure of an MDT sequence, but a number of factors should
be included. The first is a bio-psychosocial approach, which implies that
medical, psychological and social conditions, as well as environment and
personality, are regarded as contributing to the individual’s pain
experiences and responses in a complex and integrated way. The second
factor is a high intensity of treatment with activities 2–3 days per week
over a period of 6–8 weeks. The third factor is well planned and
synchronised measures, containing a psychological approach, physical
training with increasing intensity, education about pain, its consequences
and coping strategies, tasks that strengthen the individual’s decisiveness
and accountability, and strategies for return to work, e.g., through contacts
with the work place. Multidisciplinary treatment is often group based with
6–10 patients, with individual additions when necessary (Swedish
Government and Swedish Association of Local Authorities and Regions,
2011).
For CBT, the personnel must include a qualified psychologist or
psychotherapist with CBT competence or a nurse, social welfare officer,
physiotherapist or physician with supplementary education within CBT. For
MDT, the personnel must include at least three different competences,
including one physician and one qualified psychologist or psychotherapist
with CBT competence or a nurse, social welfare officer, physiotherapist or
physician with supplementary education within CBT.
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It is possible that individuals in the control group received CBT or MDT outside of
the medical rehabilitation guarantee at clinics who did not obtain a contract with
the county council. Unfortunately, we cannot observe this in the data. The county
council was eager to induce the supply of treatment in order to receive the
additional funding from the government, however, clinics with qualified personnel
should be able to receive a contract and the vast majority of CBT and MDT should
be performed within the medical rehabilitation guarantee. To the extent that the
alternative treatment is CBT or MDT provided outside of the medical rehabilitation
guarantee, this would attenuate the estimated effects of treatment.