Post on 20-Jun-2020
BriefInterventionCognitivebehaviouralTherapy(CBT)inprimaryhealthcare
StaceyRolesRN,MScNCer1fiedTrainer/Supervisor/Consultant&Diplomate-AcademyofCogni1veTherapy
PeterPagnuDRNDiplomate
AcademyofCogni1veTherapy
Faculty/PresenterDisclosure• Faculty:StaceyRolesRN,MScNandPeterPagnuDRN• Rela,onshipswithcommercialinterests:– Grants/ResearchSupport:None– SpeakersBureau/Honoraria:None– Consul,ngFees:None– Other:None
CFPCCoITemplates:Slide1
DisclosureofCommercialSupport
• Poten,alforconflict(s)ofinterest:– StaceyRolesandPeterPagnuDbothhaveprivatetherapyprac1cesandCenterforCBTSudburywhichisaprivatetrainingprogramofferingdifferentlevelsoftraining,consul1ngandsupervisioninCogni1veBehaviouralTherapywhichmaybediscussedduringthispresenta1on.
CFPCCoITemplates:Slide2
MitigatingPotentialBias• Anypoten1albiasesarebeingmi1gatedbydiclosingthepersonalbusinessupfrontandbyitnotbeingthefocaltopicofthepresenta1on.• CenterforCBTSudburyhasalsobeencer1fiedtoofferCEPDcreditsforalllevelsoftheirtraininghoursbeingoffered.
CFPCCoITemplates:Slide3
StaceyRolesrnmscn• AcademyofCogni1veTherapyCer1fiedTrainerConsultant&Therapist• Creden1aledwiththeCanadianAssocia1onofCogni1veandBehaviouralTherapies• PursuingaPhD• AdjunctprofessorwiththeSchoolofNursingatLauren1anUniversity• FacultyinthePsychiatryProgramattheNorthernOntarioSchoolofMedicine(NOSM)• LeadstheCenterforCBTSudbury;trainingandsupervisingclinicians,NPs&physicians• Avidhealthcareresearcher• WorksatHealthSciencesNorth• Presentedatnumerousna1onalconferences• Maintainsaprivateprac1ce
PeterpagnuttiRN• Cer1fiedCogni1veTherapistwiththeAcademyofCogni1veTherapy• CaseManageratHSN• Hasbeenworkinginthementalhealthfieldforover20years• HasexperienceworkingwithclientswhosufferfromseverementalillnessinbothhospitalandcommunityseDngs
• TrainsandsupervisescliniciansattheCenterforCBTSudbury• Maintainsaprivateprac1ce
QuestionsToponder
• Whatiscounselling?
• Whatistherapy?
Thetwobigquestions• WhatisCBT?
• Indica1onsforCBT
CognitiveModel
Thoughts
BehavioursEmo1ons
Situa1on
©JBeck,2011.AdaptedfromCogni1veBehavioralTherapy:BasicsandBeyond2ndEdi1onandusedwithpermission.
IndicationsforCBTandsubspecialties• Thecogni1vemodelproposesthatdysfunc1onalthinking(influencesthepa1ents’moodandbehaviour)iscommontoallpsychologicaldisturbances• Startedwithdepression(Beck)• Helpingpa1entssolveproblems• Behaviouralac1va1on• Iden1fy,evaluateandrespondtodepressedthinkingespeciallytonega1vethoughtsaboutthemselves,theirworldandtheirfuture
• Modifica1onabouttheirunderlyingdysfunc1onalbeliefsproducesenduringchange
KeyConceptsofthetherapeuticrelationship(Dinga,2008)• Trust• Communica1on• Empathy• Authen1city• Genuineness
• Listening-Ac1velistening• Timeand1ming• Empowerment
Researchsupports• Morethan500outcomestudieshavedemonstratedtheefficacyofCBTforawiderangeof• Psychiatricdisorders• Psychologicalproblems• Medicalproblemswithpsychologicalcomponents
IsCBTpossibleintenminutes?
??
Psychoeducation
• TwomainprinciplesofCBT
• Collabora1on
• Guideddiscovery
COLLABORATION• Wecannotdothisworkwithouttheclient• WecomewithknowledgeaboutdisordersandCBT• Theycomewiththeknowledgeoftheirexperience,thoughts,behaviours,environmentandemo1ons• Listen
GUIDEDDISCOVERY• Mostbeneficialinterven1onwithinCBT• Aprocessusedtohelptheclientreflectonthewaythattheyareprocessinginforma1onbyansweringques1onsandreflec1ngonthinkingprocesses
• Theycometotheconclusions• Teachthemtobecometheirowntherapist• Teachthemtono1ce,iden1fyandtheninterveneifneededtothoughts,emo1onsandbehaviours
Information-processingmodelCaseexampleofclientwithpain&chronicfatigue
©JBeck,2011.AdaptedfromCogni1veBehavioralTherapy:BasicsandBeyond2ndEdi1onandusedwithpermission.
I’mdefec1ve/worthless
+Praisefromfamilyformakinganice
dinner
+Washedthedishes
+watchedmy
daughtersdogforher
+Paidmybills
–DifficultygeDngtoappointments,
someonehastotakeme(burden)
_ButIdidn’tdeserveitbecauseI
burneditwhenIfellasleepmiddleoftheday
–DifficultydoingADLS
r/tpain
_Butittookmealong1me
12CommonCognitiveErrors1.All-or-nothingthinking(alsocalledblack-and-whitethinking)
2.Catastrophizing(alsocalledfortune-telling)3.Disqualifyingordiscoun,ngtheposi,ve4.Emo,onalreasoning5.Labeling6.Magnifica,on/minimiza,on7.Mentalfilter8.Mindreading9.Overgeneraliza,on10.Personaliza,on11.“Should”and“must”statements12.Tunnelvision©JBeck,2011.AdaptedfromCogni1veBehavioralTherapy:BasicsandBeyond2ndEdi1onandusedwithpermission.
WhatDoesBriefInterventiontherapylooklike?• Iden1fyissueofconcern• UseSocra1cDialoguetoiden1fybehaviours/thoughts/emo1ons• Challengethethoughts• Thoughtrecords• Prosandconslists
• Developbehaviouralexperiments• Seewhathappenswhentheytryit(becurious)
• Implementthesmallestamountofachievablechangepossible
CBTapplicationThoughtRecord
Wherewereyou?
Emo,onorfeeling
Nega,veAutoma,cThought
Evidencethatsupportsthethought
Evidencethatdoesn’tsupportthethought
Alternatethought
Emo,onsorfeelings
BehaviouralActivationandMastery• Iden1fycurrentorpreviouslifegoals• Socra1cdialogueandguideddiscovery• whytheystoppedpersuadingthesegoals
• Socra1cdialoguetodetermineifthesegoalsares1llapriorityandifnotwhathavetheyshinedto
• Discoverthedissonancefromwheretheyarenowtowheretheirgoalsare• Determineifthereisanopennesstothebeliefthatdailyac1va1onaccumulatestolongtermgoals
CBTapplicationBehaviouralExperiments
• Thegoalistocollabora1velyiden1fyahypothesisabouttheoutcomeofabehaviourandthendeterminewhatbehaviouralexperimentswouldtestthathypothesis• Itimportanttoensureyoudevelopwithyourclientameansofmeasuringtheresults• Ini1allytrytogeartheoutcometoaposi1veachievement
Howdowedothis?
• Socra1cDialogue• TheycomeupwiththeirownCOGNITIVEsugges,ons• Iden1fyingcogni1vedistor1ons(Ican’tdoit,I’llneverbeabletodoit,CATASTROPHIZING)
• HavethemcomeupwiththeirownBEHAVIOURALsugges1ons• Walkdownthehalldaily• Takestairsinsteadofelevator
Pleasanteventsforbehaviouralactivation
• Ratedifferentlifeevents• Howonenitoccurs• Iftheeventisnotpleasant,somewhatpleasantorhighlypleasant
• Someeventsmayinclude• Talkingaboutsports• Breathingcleanair• Beingwithanimals• Scratchingmyself• Takingabath• Dancing
• Thesecanbeusedasbehaviouralac1va1onbyjournalingthemonapleasanteventcalendar
IsAnxietyBad?
• Goalwillbeto“getridofanxiety”• Anxietyisnotbad,itkeepsussafe• Whatwouldhappenifwedidn’thavefear?
• Anxietyandfearresponse• Fight,flightorfreeze
Fearisthecommontheme,sowhatisthecommonsolution?
• Relaxa1on• Deepbreathing• Mindfulness• Medita1on• ProgressiveMuscleRelaxa1on
ProminentCognitiveErrorswithAnxiety1)Overes1ma1ngtheprobabilitythatbadthingswillhappen2)Underes1ma1ngabilitytocope3)Underes1ma1ngrescuefactors
Copingstatementsforpatients
(Leahy,2012)
Habituation
• Simplymeansthatwereactlessandlesstos1muliover1mewithrepeatedpresenta1on• Ifwewatchascarymovieoverandoveragainitusuallybecomeslessscary• In-VivoExposures• ImaginalExposure
Healthanxiety• Avoidancecanbereassurancechecking• ExposurecanbesiDngwithuncertainty(discomfort)• Perceivedriskvsactualriskwithhealthissues• Howmany1mesadayaretheychecking?Howlongdoesrelieflastoncetheygetreassurance?Howmuchworsedoesitgeteach1me?• Cost/Benefitanalysis
DepressionandSuicidalThoughts• Riskassessment:• Ifunsureofsafetytoclient,selforothers,alwaysconsultwithorrefertocrisisorotheragenciesinyourarea
• Knowtheseemergencyservicesandhowtocontactthemandensureyourclienthasaccesstoasafetyplanaswell
• Safetyisparamount
§ CrisisPlan:§ Supports/contacts§ Crisisphonenumbers§ Emergencydepartmentphonenumbersandloca1ons
WhenandWheretorefer?• LetsDiscuss…..• Anyimminentthreattoselforothers?• Differencesbetweenprivateprac1ceandpublic• Differencesbetweenserviceproviders
Questions?
References• Beck,J.(2011).Cogni1veBehaviorTherapy:BasicsandBeyond2ndedi1on.GuilfordPublica1ons,Inc;NewYork,NY.
• Dinga,V.,&Karvinen,O.(2008).BuildingTherapeu1cRela1onshipswithMentalHealthClientsinPrimaryCareSeDngs:aliteraturereview.NursingPeplau
• LeahyR.(2012).TreatmentPlansandInterven1onsforDepressionandAnxietyDisorders2ndedi1on
• Sadock,B.,&Sadock,V.(2007).KaplanandSadock’sSynopsisofPsychiatry:BhavrioalSciences/ClinicalPsychiatry;10thedi1on.LippincowWilliams&Wilkins;Philaderphia,PA.
• Sudak,D.,Codd,R.,Ludgate,J.,Sokol,L.,Gox,M.,Reiser,R.,&Milne,D.(2016).TeachingandSupervisingCogni1veBehavioralTherapy.Wiley&Sons,Inc;Hoboken,NewJersey.
• Theore1calFounda1onsofNursing;Peplau[online]hwp://nursingtheories.weebly.com/hildegard-e-peplau.html
Howtogetmoretraining• WeoffertrainingforprimaryhealthcareprovidersincludingCEPDcreditsforphysicians
• Onsiteorourloca1ontrainingrequestsfor4or7hoursdirectedatrequestedtopicoffocus
• Intensivetrainingtwiceperyear• Websitewww.centerforcbt.ca• Phone(705)929-1612