CBT / PST Treatment Brief Therapy. Objectives. Lesson learned. Many new tools to help meet the current needs. Current working environment

Transcription

1 CBT / PST Treatment Brief Therapy Rita Haverkamp The speaker has no conflicts of interest to disclose All images used are clipart MSN, PMHCNS-BC, CNS Objectives By the end of this session, you will be able to Review the basics of CBT through emphasis on the problem solving aspects- PST Identify some basic tools you can use to implement CBT or PST with your patients Discuss implementation of this technique and how it would work in your practice Lesson learned Anything you say to a patient matters Current working environment Brief treatment -shorter time or number of sessions Working in PC, FQHC, rural areas, private practice Meeting patients where they are and empowering them for self care Assessing medication response and doing therapy in same appointment Many new tools to help meet the current needs Screening tools Measurement of improvement Evidenced based care Training and certification processes in EBT s Rita Haverkamp, MSN, PMHCNS BC,CNS 1

2 Behavioral Health Measures as Vital Signs Behavioral health screeners are like monitoring blood pressure! Identify that there is a problem Need further assessment to understand the cause of the abnormality Help with ongoing monitoring to measure response to treatment Advantages Graph of PHQ9 Objective assessment Creates common language Focuses on function Avoids potential stigma of diagnostic terms Helps identify patterns of improvement or worsening Flexibility of administration Saves time for therapy Cycle of Depression Cognitive behavioral treatment Nothing is either good or bad, but thinking makes it so. -Hamlet I choose to be happy regardless of what happens. Anonymous Change your thoughts, change your world. Anonymous Rita Haverkamp, MSN, PMHCNS BC,CNS 2

3 Cognitive Behavioral Treatment Thoughts a powerful force Brief evidenced based treatment Goal to change patterns of thinking or behavior that are behind people s problems/ difficulties Patient empowerment Structured and educational approach Generally there is home practice involved Events---Thoughts--Feelings Action You can help the patient intervene in the thoughts- cognitive treatment the actions behavioral treatment Cognitive approaches Negative feelings can result in reacting poorly to situations, avoiding problems, misperceiving situations Problems develop out of these feelings and reactions to the feelings Recalculating or red flag thoughts Education of the process Devils advocate Having patients write a log of eventthoughts- feeling- alternative thoughtsalternative action Thought log Situation Feeling Thoughts Cognitive distortion Alternative/ healthy thoughts Alternative actions Simple CBT technique red flag Notice an emotion- Think about what is happening Catch your thoughts that led to this Argue against those thoughts- think of alternative explanations Act in a new way Rita Haverkamp, MSN, PMHCNS BC,CNS 3

4 Thought log Situation: Feelings: Thoughts: Thought distortions: Alternative thoughts: Resources for patients Feeling Good by David Burns Healthy Body, Healthy Mind by David Sobel, Robert Ornstein Being Happy by Andrew Matthews- more low key Websites or apps Alternative actions: Cognitive distortions/unhealthy thoughts A way our mind convinces us of something that isn t true Reinforces your negative thoughts Creates negative emotional responses Learned patterns of thinking automatic thoughts Cognitive distortions Overgeneralization All or nothing thinking Shoulds Catastrophizing Jumping to conclusions PST as a part of CBT PST: a patient-directed process Most CBT evidenced based studies include a problem solving module. PST can be done as a treatment by itself and with other cognitive approaches Patient identified problems Teach patient structured technique for solving problems Help patients understand connection between depression, problems and solving problems Rita Haverkamp, MSN, PMHCNS BC,CNS 4

5 Seven Steps of PST-PC Orient, Clarify and Define the Problem Set Realistic Goal Generate Multiple Solutions Evaluate and Compare Solutions Select a Feasible Solution Implement the Solution Evaluate the Outcome Link Between Problems, Depression, and PST Unresolved life problems can cause and worsen depression Worsening mood interferes with problem solving Downward spiral between problems and mood PST strengthens problem solving skills Improved problem solving lifts mood Improvement follows action Establish Positive Problem Orientation- this is where some of the C of CBT is done Problems are a normal part of living Negative mood may indicate a problem Some degree of control can often be achieved Effective solutions exist at least in part, if not in total All problems will not be solved in these sessions Problem Definition A problem well-stated is a problem half solved. Kettering Concrete and specific terms Assumptions versus facts Details Breaking down problems Goal Setting Goals are dreams we convert to plans and take action to fulfill. Zig Ziglar Specific Attainable Realistic Measureable Brainstorming Don t put all your eggs in one basket anon. All ideas that come to mind Withhold judgment Be detailed Generate five Rita Haverkamp, MSN, PMHCNS BC,CNS 5

6 Decision Making Again and again, the impossible problem is solved when we see that the problem is only a tough decision waiting to be made. Robert H. Schuller Weighing the pros and cons Does it meet immediate goal? Does it meet long term goal? Does it create other problems? Is it feasible? Selecting the Solution You are the sum total of all your choices up to now. Dr. Wayne Dyer One with the most pros and least cons Most feasible Less amount of effort Solution Implementation Even if you are on the right track, you ll get run over if you just sit there. Will Rogers Steps to implementation Specify when will do (earlier the better) Delegate When to check in Do you need other people to help? Solution Evaluation When you lose, do not lose the lesson. The 14 th Dalai Lama Did it work? If so, why? Would you do anything differently? Will you use this solution again? If not why? What did you learn? Does the problem need to be redefined? Rewards and Activities One joy scatters a hundred griefs. Chinese proverb Make sure includes pleasant activities Include a reward for hard work Reinforce patient efforts at change PROBLEM-SOLVING WORKSHEET Name: Date: Visit #: Review of progress during previous week: Rate how Satisfied you feel with your effort (0 10) (0 = Not at all; 10 = Super): _9 Mood (0-10): _6 1.Problem: Head ache- will be visiting Mother soon, visits lead to doing what her Mother wants to do- especially cooking and pt doesn t get much time with her own children and grandchildren 2.Goal: Have time alone with children/grandchildren and cook less for her Mother 3.Options/Solutions 4. Pros versus Cons (Effort, Time, Money, Emotional Impact, Involving Others) a) talk to Mother about a) Pros (+) What makes this a good a) Cons the issues fear / mother would get upset and probably not adult thing to do agree it is a problem/ may not end up happening b) stay at son s house b) Pros (+) What makes this a good b) Cons mother paid transportation/ feel guilty/ does Free of mother want to see her c) go out to eat c) Pros (+) What makes this a good c) Cons cost issues but can find inexpensive places Helps with less work, mother enjoys this d) spend some days at d) Pros (+) What makes this a good d) Cons son s house mother could be unhappy/effort to packing and Combines both visits/ get special time with unpack grandchildren Rita Haverkamp, MSN, PMHCNS BC,CNS 6

7 PROBLEM-SOLVING WORKSHEET Continued 5. Choice of solution: stay a few days with son, go out to eat 6. Action Plan (Steps to achieve solution): Write down the tasks you completed. a) Talk to son about the plan tomorrow- practice wording of talked to son how to tell mother with son so he can support the plan b) take these days in middle of trip took the middle days c) tell mother a few days before going rather than prior to did this trip d) go out to eat a number of times on the trip went out a few times Pleasant Daily Activities Rate how Satisfied it made you feel (0 10) (0 = Not at all; 10 = Super) Date Activity Daily work on puzzle, read Sat walk with friend Next appointment: PST-PC Selected Reference List 1. Malouff JM, Thorsteinsson EB, Schutte NS. The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis. Clin Psychol Rev Feb 8 2. Alexopoulos GS, Raue P, Arean P. Problem-solving therapy versus supportive therapy in geriatric major depression with executive dysfunction. Am J Geriatr Psychiatry Jan-Feb;11(1): Barrett JE, Williams JW Jr, Oxman TE, Frank E, Katon W, Sullivan M, Hegel MT, Cornell JE, Sengupta AS. Treatment of dysthymia and minor depression in primary care: a randomized trial in patients aged 18 to 59 years. J Fam Pract May;50(5): Mynors-Wallis L. Problem-solving treatment: evidence for effectiveness and feasibility in primary care. Int J Psychiatry Med. 1996;26(3): Arean PA, Perri MG, Nezu AM, Schein RL, Christopher F, Joseph TX. Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults. J Consult Clin Psychol Dec;61(6): Hegel MT, Dietrich AJ, Seville JL, Jordan CB. Training residents in problemsolving treatment of depression: a pilot feasibility and impact study. Fam Med Mar;36(3): Mynors-Wallis, L., Gath, D., Day, A., Baker, F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for depression in primary care. BMJ 2000;320; Rita Haverkamp, MSN, PMHCNS BC,CNS 7