Implementing Cognitive Behavioral Skills in Routine Clinical Practice: Reflecting on the Five Areas Model and More

Transcription

1 Implementing Cognitive Behavioral Skills in Routine Clinical Practice: Reflecting on the Five Areas Model and More Margaret Elizabeth Myers, PhD, RMFT, CCC-S, RP Len Myers, BA, M.Div, D. Min., RMFT

2 Routine Clinical Practice 1. Not specialized practice; perhaps generalized client mix ; 2. Counsellor is comfortable with own knowledge/understanding of client groups ; 3. Not cases you seek consultation/supervision for or refer; 4. Session-to-session evaluation of clients progress occurs.

3 Competencies for CBT Therapy Meta Competency Problem Specific Competencies req. Sup (Exposures, DBT, OCD Groups) Additional Model (req. Training/Evaluation) (CBT) Fundamental/Generic Psychotherapy Skills (Roth & Pilling, 2007)

4 Base Level: Fundamental/Generic Psychotherapy Skills Knowledge of Mental Health Issues Assessment Skills/Implement Interventions Professional and Ethical Guidelines; Discerns Competency/Client Requirements; Assess Need for Referrals for Clients/CE/Supervision for Self; Generic Model of Therapy/Implements Model in Practice (ie. Gerald Corey); Effectively Deals with Emotional Content of Sessions (Deal with our own stuff Engage Client/Foster & Maintain Therapeutic Alliance Understand Clients World View/ Manage Endings Displays Warmth, Acceptance, Empathy, & Focus on the Other Fundamental/Generic Psychotherapy Skills

5 There are many Models and Specialties Art Therapy Attachment Models Cognitive-Behavioural Therapy Couples/Relationship Models Culturally Specific Models Emotionally-Focused Therapy (Individual and Couples) Eye-Movement Desensitization and Reprocessing (EMDR) Family Systems Theories (various) Family Therapy Models Internal Systems Model Music Therapy Narrative Therapy Person-Centered Therapy Play Therapy Schema Therapy (and more..) Using Additional Models Fundamental/Generic Psychotherapy Skills

6 Problem Specific Competencies Generally requiring additional study and supervision Includes, but not limited to : 1. Exposure Therapy; 2. Personality Disorders (the 10/ all A,B,C Clusters: Antisocial; Avoidant; Borderline; Dependent; Histrionic; Multiple; Dissociative Identity Disorder; Narcissistic; Obsessive-Compulsive (not OCD); Paranoid; Schizoid[ & Schizotypal); 3. Group CBT. Problem Specific Competencies req. Sup (Exposures, DBT, OCD Groups) Using Additional Models Fundamental/Generic Psychotherapy Skills COMPANY NAME

7 Meta Competencies The Tip of the CBT Competency Pyramid Meta Competencies Can work across all levels of client issues, and adapt CBT to the needs of each individual client. Mindful Practice Supervised Supervision Not rote practice, maker higher order link between theory and practice, use of critical thinking

8 Meta Competencies Don t Automatically Appear Meta Competency Problem Specific Competencies req. Sup (Exposures, DBT, OCD Groups) Additional Model (req. Training/Evaluation) (CBT) Fundamental/Generic Psychotherapy Skills

9 Benefits of CBT Collaborative/Therapeutic Alliance; Client focused Theory of psychopathology/treatment Short-term/Cost Effective Objective Assessment and Monitoring/Scales/Tools Strong Empirical Support Effective with Medication; use alone/ with Medication Structured, Goal Oriented; Focus on Immediate Issues + Long Term Strategies; Requires Active Involvement by the client Flexible, Individualized, adapted to a wide range of clients and settings

10 Therapist Related: False Claims Made, Mechanistic Approaches Beck is Warm, Safe.. Big Pharma Issues CBT & Bad Press Professional Amnesia (Kelly Bundy Syndrome); Knowledge Accumulates Lack of Motivation/Commitment in Clients Addicted Client Still Drinking/Using Active Paranoid Personality Disorder Therapist lacks interaction skill mix (assertive, directive, nonjudgmental & collaborative) Client Lacks Time Necessary; Resents Time to Use Logs/Other assessments Client Overwhelmed and Still on the Wheel; Lacks Basic Support Client Refuses Homework, Fix Me Here [168 hrs in week] SMI; Axix 11 not diagnosed. DSM5; ICD 10

11 But What About That Window of Opportunity? After Fundamental/Generic Psychotherapy Skills Add to Fundamental/Generic Skills Without Becoming a CBT Specialist Add to Existing Psychotherapy Skills Without Becoming a CBT Specialist After Fundamental/Generic Psychotherapy Skills and learning other Model/s

12 The Legacy of Aaron T. Beck Example text Dr. Aaron Temkin Beck (Tim) Born July 18, 1921 Globally recognized as the father of Cognitive Therapy (CT) One of the world's leading researchers in psychopathology Psychiatrist; Worked as psychoanalyst

13 The Legacy of Beck Psychoanalyst (1940) found basic concepts of depression to be false; Re-conceptualized the cause and trajectory of Depression and Reaction from his peers.?? Point # 2 Tim EBP: Researchers world wide empirically tested theory in numerous conditions Beck Institute of Cognitive Behaviour Therapy Academy of Cognitive Therapy (Certification and Registration)

14 Controlled Outcome Studies on CBT Unipolar Depression Eating Disorders Anorexia Bulimia Generalized Anxiety Disorder Social Phobia Panic Disorder Borderline P.D. Schizophrenia Chronic Depression

15 CBT Used for Clients with. Mood Disorders Unipolar Depression Bipolar Disorder Dysthymia and Chronic Major Depressive Disorder (CMDD) Anxiety Disorders GAD Social Phobia Panic Disorder OCD PTSD

16 Altered Eating Disorders GBR (Obesity) CBT: Clients with LBR (Anorexia; Bulimia; Healthy BMI) Marital Problems Other Headaches; Insomnia; Chronic Pain; Smoking Cessation; Hypochondriasis; Body Dysmorphic Disorder

17 Yes Maggie, but What About that Window of Opportunity? After Fundamental/Generic Psychotherapy Skills Add to Fundamental/Generic Skills Without Becoming a CBT Specialist Add to Existing Psychotherapy Skills Without Becoming a CBT Specialist After Fundamental/Generic Psychotherapy Skills and learning other Model/s

18 The Five Areas Model: De-Jargonizing CBT Life Situations Relationships Practical Problems Example text Altered Thinking Altered Emotions/ Mood/ Feelings Altered Physical Feelings/ Symptoms Altered Behaviour/ Activity Level Use [recommended] to wide range of HC practitioners including day-hospital and community based psychiatrists, psychiatric nurses, clinical psychologists, behavioural therapists, general practitioners, etc. Not a new approach, but a new way of communicating the existing CBT approach to [wide range of practitioners]

19 Standard Course of CBT 1. Assessment 2. Provide Rationale 3. Training in Self-Monitoring 4. Behavioral strategies 1. Monitor relationship between situation/action and mood. 2. Applying new coping strategies to larger issues. 5. Identifying beliefs and biases 6. Evaluating and changing beliefs 7. Core beliefs and assumptions 8. Relapse prevention and termination

20 How can you do this? Collaborate with Client/ Build therapeutic alliance; Show Genuine Concern Explain how CBT works Collaborative Goal Setting Show Genuine Empathy and Concern for Client Safety Assessment Accepting WHO the Client IS: Let him Live in His Own World (Peeps/Culture/ Sexual Orientation/Gender/Roles/Values/Health/Faith/Spirituality) Level of Support & Realistic Expectations (Who can you call at 2 am?) Client s Experiences with Mental Health Professionals? Listen Well Before Conceptualizing Listen for Family History, Experiences; How Sense of Self Developed. Genogram (in your head if possible) Socratic Questioning Listen for Negative Automatic Thoughts Listen for Hope; Build on Hope/Positive Coping Skills; Listen for Hopelessness: Immediate response Necessary! Listen for Survival Narrative; How does client see herself Use Assessment Tools; Introduce Logs: Cognitive Restructuring Process

21 Socrates ( BCE) Socrates: First Cognitive Therapist in the West Revealing the Issue: What evidence supports this idea? And what evidence is against its being true? Considering Reasonable Alternatives: What might be another reason explanation or viewpoint of the situation? What else might be happening? Examining Various Potential Consequences: What would be the best outcome? A bearable one? The most realistic one? Evaluating Consequences: What do you feel like when you believe X? What do you think you would feel like if you no longer held onto this belief? Distancing: Imagine A (friend/family member) in the same situation or

22 W H Question Types Who What Where When Why How How Much

23 Schema, Assumptions, Dysfunctional Beliefs, Irrational Beliefs Schemas (Belief set about the Self, Others, and the World) Experiences are screened through schemas Strong maintenance systems/ Difficult to change Negative Assumptions Look for confirmation Schemas of Mistrust, Entitlement, Avoidance, Dependence Rigid Rules My Rules for Living My Thoughts Myself/ My Screens

24 The CBT Model

25 Thoughts Triggering Event Behaviour Feelings

26 Behaviour NATs Feelings Behaviour NATs Feelings

27 The Basic Cognitive Model Beliefs and Assumptions Triggering Event Automatic Thoughts Emotional & Behavioural Responses

28 Triggering Event (Partner leaves relationship/ Job Loss, etc). Behavior Avoids family/friends; withdrawal Resilience Level Perception of Event I m no good. It s my fault. I should have been more.. Depressed Mood I can t deal with it. I can t cope Changes in Activity Level Low energy, disruption of sleep, increased fatigue

29 Help Client to Develop more Flexible Rules OLD RULE: I cannot show weakness to anyone at any time NEW RULES: It might be possible to show my weak points to some people some times. I can explore different ways of showing weak points some might be better than others. Taking the initiative sometimes could give me more sense of control. Taking the initiative sometimes might also lessen the sense of dread about being found out.

30 Where is the Client s Resilience? Capacity to Roll with the Punches? Flexibility, Competence and Self-Efficacy (Bandura, 1977) Find the Resilience; the Strengths in Current Life Research: resilience in procedural knowing /early attachment relationships. Internalized dyadically: balanced between stability (not too rigid) and flow (not overflowing) When regulation and empathy imbalanced, resilience compromised. NATs Clients often present with a lack of resilience, become overwhelm, confused, passive, feel helpless. Return to Schematic Scripts. Re-Write Rules for Living Rupture vs. Repair; Retreat vs. Assertively Negotiate; Emotional Cut-Off vs Re-Connection, etc. New patterns, behaviors, strategies; confidence/ self efficacy possible

31 Automatic thoughts (NATs) center around one s: View of Self View of Others/World View of Future

32 The Negative Triad Negative Triad Associated with Depression Self: I am incompetent/unlovable Others: People do not care about me Future: The future has no promise Negative Triad Associated with Anxiety Self: I am unable to protect myself Others: People cannot be trusted Future: It s a matter of time before they hurt me

33 Assessment with a Specific Purpose

34 As part of Professional Practice, you are Already Assessing Conceptualizing Planning Implementing Evaluating (Put on a different pair of glasses)

35 Conceptualization the Client s presenting profile Depression: Negative view of self, others, and future. Core beliefs associated with helplessness, failure, incompetence, and not loveable Anxiety: Overestimation of physical and psychological threats. Core beliefs linked with risk, level of danger, and one s inability to control

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37 Cognitive Conceptualization Triggering Event NATs About Self, World and Others Physiology Feelings Behavior Early Life Events Underlying Assumptions and Core Beliefs Compensatory Strategies

38 Triggering Event Boyfriend says: I need time to be with my friends Childhood Experience Saw Dad twice in 10 years; Mother critical and demanding For Example NATs Automatic response: Oh no, he s losing interest and is going to break up with me. Underlying Assumptions & Core Beliefs I m was never good enough; boyfriend has finally seen the Real Me, People can t be trusted to care about me. Physiology Heart racing Lump in throat Feelings Sadness Worry Anger Behavior Seek reassurance Withdraw Cry Compensatory Strategies Be independent and you ll be safe. Watch out people are careless with you.

39 Triggering Event Failed a Mid- Term Test Early Experience Parents highly focused on academic results and future career Another Example NAT I am not going to get through this course and I won t get into med school. I m not as smart as everyone else. People will discover this and I will be so ashamed. Underlying Assumptions If I don t do well academically, I m a total failure to my parents. My life will be ruined Physiology Pit in stomach Dry mouth Feelings Worry, shame, Disappointment Humiliation. Behavior Use alcohol, Procrastinate with homework Compensatory Strategies Work extra hard to offset incompetence.

40 Cognitive Distortion Emotional reasoning All or Nothing Thinking Fortune telling Should Statements Labelling Personalization Catastrophizing Mind Reading Disqualifying the positive Selective Abstraction Overgeneralization Example I feel hopeless so the situation must be hopeless My girlfriend broke up with me. I ll never meet anyone else I know I won t get the job, so why should I try I should be able to door more, look better, etc. I m a failure; I m lazy; I am not loveable The accident happened because I m being punished If I don t get this job, no other job will be right for me I know they say nasty things about me That doesn t count because. He said I need improvement an area, so he thinks I m incompetent Mary doesn t like me; nobody likes me

41 Irrational/Core Beliefs Demand for Approval Overly high expectations Blame Proneness Lack of Acceptance Emotionally Helplessness Anxious Over concern Problem Avoidance Dependency Indelible past Perfectionism Example If someone doesn t like me, I must be bad To be worthwhile, I must be competent in every area Certain people are bad and should be punished Things are horrible when not the way I want them to be Misery is externally caused and I have no control over it If something is remotely possible, I have to constantly be on my guard Facing difficulties is too hard and its best to do nothing I need someone stronger than me to rely on If something once had an effect on my life, that will never change There is one right and correct way to do things

42 Irrational/Core Beliefs Underlie and produce automatic thoughts. Assumptions that influence our understanding about ourselves, others, and the future. Latent until activated by stress/negative life events Categories of core beliefs (helpless, worthless, unlovable) Core Beliefs Automatic Thoughts

43 Examples of Core Belief Sets Helpless core beliefs I am inadequate, ineffective, incompetent, can t cope I am powerless, out of control, trapped I am vulnerable, weak, needy, a victim, likely to be hurt I am inferior, a failure, a loser, defective, not good enough, don t measure up Unlovable core beliefs I am unlikable, unwanted, will be rejected or abandoned, always be alone I am undesirable, ugly, unattractive, boring, have nothing to offer I am different, flawed, defective, not good enough to be loved by others Worthless core beliefs I am worthless, unacceptable, bad, crazy, broken, nothing, a waste I am hurtful, dangerous, toxic, evil I don t deserve to live

44 Responding to Negative Thoughts Define Situation: I m hearing you say that Clarify meaning of cognitive appraisal What was going through your mind just then? What did the situation mean for you? Evaluate interpretation Evidence: For and against this belief? Alternatives: Any other explanation(s)? Implications: So what.?

45 CBT Requires Full Client Commitment to the Process

46 Sample Thought Log Situation Thoughts Emotions Rational Response Outcome Going on vacation Ask a colleague to do some work for me She ll say no I m not doing a good job The boss thinks I take too much time off Anxiety (70%) Guilt (40%) Sadness (20%) I haven t taken a day off in 6 months. We work as a team, so it s also her job to track the samples. Anxiety (10%) Guilt (0%) Relief (40%) Cognitive Distortions: All/nothing Mindreading Fortune- Telling Overgeneralization

47 Basic Principles of CBT Change mood states by using cognitive and behavioral strategies: Identifying/modifying automatic thoughts & core beliefs, Regulating routine, and Minimizing avoidance. Emphasis on here and now Preference for concrete examples Start with specific situation (complete thought log) Reliance on Socratic questioning Ask open-ended questions Empirical approach to test beliefs Challenge thoughts not based on evidence Cognitive restructuring Promote symptom change

48 Behavioral Interventions Breathing retraining Relaxation Behavioral activation Interpersonal effectiveness training Problem-solving skills Exposure and response prevention Social skills training Graded task assignment

49 Cognitive Interventions Monitor automatic thoughts Teach imagery techniques Promote cognitive restructuring Examine alternative evidence Modify core beliefs Generate rational alternatives

50 What works in CBT? Developing the Therapeutic Relationship Shared Problem Definition/Collaborative Decision Making Agendas, Goals, Plans, Instruments (BDI, BAI, Thought Records/Active Experiments) Examination of cognitive beliefs and developing rational responses to NATs Cognitive Restructuring/Behaviour Experiments /Activation (observing, comparing, reflecting, imitating and experimenting) Relapse Prevention

51 Circumstances in which CBT is indicated? The client prefers psychological interventions, alone or in addition to medication The Target CBT Problems are present (extreme, unhelpful thinking; reduced activity; avoidant or unhelpful behaviours) No improvement/ partial improvement on medication Side-effects prevent an effective medication dosage (over an adequate period) Significant psychosocial problems (e.g. relationship problems, difficulties at work or unhelpful behaviours such as self-cutting or alcohol misuse) present that will not be adequately addressed by medication alone

52 Advantages of CBT Short Term (average 16 sessions) Problem Focused Psychosocial Intervention (emphasis on long-term results --correcting problematic underlyi assumptions) Evidence based from randomized controlled trials and meta-analysis Clear underlying model/structure/plan Cross-cultural; based on universal laws of human behavior. Fundamental principle (that thoughts cause feelin and behaviours) makes CBT Adaptive Focuses on the client's goals, not therapist's goals; Timely; focuses on current problems relevant to the client Structured and results focused, but not mechanistic; reduces the possibility that sessions will become "chat sessions" in which not much is accomplished therapeutically Compatible with a range other treatments such as medication or supportive counselling Because the individual is actively involved in their treatment they are more likely to stick with it. Client can use CBT model to approach other problems in life. Client is actively involved in treatment and more likely to stick with changes made Flexible and individualised, it can be adapted to a wide range of individuals and a variety of settings.

53 Disadvantages of CBT To benefit from CBT, client must be committed to the process. Does not work without client participation. 16 hrs/wk 167 outside therapy Attending regular CBT sessions and carrying out necessary homework is time consuming Because of structure, can be challenging for people with complex mental health needs or learning difficulties Because emotions and anxieties are challenged, there are often initial periods of more anxiety/emotional discomfort Many current issues are rooted in unhelpful distortions created in childhood, and CBT does not focus on childhood issues or underlying causes of mental health conditions CBT focuses on client capacity to change themselves (their thoughts, feelings and behaviours), and does not address wider problems in systems or families that often have a significant impact on an individual s health an wellbeing. Collaborative Relationship is Essential; Requires therapist knowledge and skills in therapeutic presence and partnering relationships In great demand but limited numbers of specialized therapists trained; post-grad training is expensive and limited to larger centers Highly technical language and jargon needs to be unplugged to be useful to clients (Beck s 1979 CT of Depression dense Flesch-Kincaid 17 years education) Insurance companies are 20 years behind in understanding EBP

54 Classic CBT Terms Use Reasonable Language Jargon Unplugged 1. Thinking Errors/Faulty Information Processing 1. Unhelpful Thinking Styles 2. Negative Automatic Thoughts (NATS) 2. Extreme Thinking/Unhelpful Thinking 3. Arbitrary Inference 3. Jumping to Conclusions 4. Selective Abstraction 4. Putting a Negative Slant on Things 5. Overgeneralization 5. Making Blanket Statements or Rules 6. Magnification and Minimization 6. Focusing on the Negative and Downplaying the Positive 7. Personification 7. Taking things to heart; Taking unfair share of respons 8. Absolutistic Dichotomous Thinking 8. All or nothing (black or white) thinking 9. Cognitive Distortions 10. Cognitive Schemas 10. Ways of looking at yourself, other people and the wo

55 C Cognitions The Vicious Cycle of the C and the B & Benefits of T (Depressed or Anxious): Unhelpful; self-critical/dismiss strengths; dwe past; negative slant; negative predictions about the future; jump to conclusions; m second-guess others; feel overly responsible; overly high standards for self and/or of proportion thoughts B (Altered) Behaviour to Feel Better: (Reduced Activity/Avoidance): With depression anxiety, normal to experience difficulty doing things. Low energy, tiredness; Negative Thinking, so decreased interest in events, experiences, Low Mood, so reluctance to take part in activity Feelings of guilt, so don t deserve pleasure Anxious thoughts, so reduce activity, things and places Lak of activity/avoidance exacerbates feelings of depression/anxiety T Because problems are maintained by vicious cycles of C & B, the goal of Therapy is client to identify and break cycles that are part of the current problem ive Areas ssessment Five Areas Assessment Model informs treatment Informs the impact of problem on client s life Helps clients gain insight into relationship between C & B Does not rule out life events & relationships, hereditary factors, neurochemistry, v learning from modelling

56 Give Clients Tools and Measure Progress PRESENTER NAME

57 Encourage Consistent Use of Tools

58 Encourage Excitement about Progress!

59 Encourage Support Systems PRESENTER NAME

60 Journey With Clients Your footnote

61 See Them Meet Their Goals

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63 References Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, Garland, A., Fox, R., & Williams, C. (2002). Overcoming reduced activity and avoidance: a Five Areas approach. Advances in Psychiatric Treatment, 8: Williams, C., & Garland, A. (2002). A cognitive-behavioural therapy assessment model for use in everyday clinical practice. Advances in Psychiatric Treatment, 8, Roth, A.D., & Pilling, S. (2007). The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders. A Report Commissioned by Centre for Outcomes, Research and Effectiveness (CORE), Sub- Department of Clinical Health Psychology, University College London, UK. petence_list.pdf Williams, C., & Garland, A. (2002). Identifying and challenging unhelpful thinking. Advances in Psychiatric Treatment, 8: Whitfield, G., & Williams, C. (2003). The evidence base for cognitive behavioural therapy in depression: delivery in busy clinical settings. Advances in Psychiatric Treatment, 9: Wright, B., Williams, C., & Garland, A. (2002). Using the Five Areas cognitive- behavioural therapy model with psychiatric patients. Advances in Psychiatric Treatment, 8:

64 A talk psychotherapy Short-term focused treatment Common Components of CBT Empirical support with randomized clinical trials As effective as medications/ use with medication or when medications are contraindicated/ineffective. Therapy defined by cognitive conceptualization Establish good therapeutic relationship Educate patients - model, disorder, therapy Assess illness objectively, set goals Use evidence to guide treatment decisions Structure treatment sessions with agenda Limit treatment length Issue and review homework to generalize learning