Brief Health Focused Culturally Responsive

CBT Transforming suffering to strengths - Lecture and Training #2

Evidenced Based Practice

CBT – Simple Overview

Simple overview…

CBT is a time limited, collaborative, here and now focused treatment aimed at helping patients through developing more accurate healthy thoughts, increased coping skills, behavioral activation and emotional regulation skills.

Brief CBT – Non-Specific Factors

Three Key Parts of Health Focused CBT

• Functional Assessment: Looks at the real life way that mental and physical health challenges arise. Not simple that some one is depressed… but what is that depression in this person’s life.

• Skills Training: Is active and focused on helping enhance the ability to change thoughts, improve emotions and take effective actions.

• Changing Thoughts: Negative thoughts are a core part of how CBT conceptualizes mental suffering. Clinicians help patients gain skills to challenge their thoughts, recognize distorted thinking, find more accurate and helpful thoughts and cope cognitively.

Beck Video

The Core Levers of Change…

What Creates Change?

In CBT the core of human suffering is developed by any one of the core components. These are thoughts, feelings and behaviors.

If a patient changes how they act it will change their thoughts and if they change their thoughts they can change how they act.

The Cognitive Triad

Cognitive Distortions

Cognitive distortions are common and habitual ways that people can misinterpret situations,

events, others, and expectations about the future.

Beck Video

Automatic Thoughts

Automatic Thoughts Lead to Behaviors

Automatic Thoughts Lead to Core Cognitions

Exercise Teaching Thought Log

Brief CBT Interventions

• Brief CBT is the compression of CBT material and the reduction of the average 12-20 sessions into four to eight sessions. In Brief CBT the concentration is on specific treatments for a limited number of the patient’s problems.

• Brief CBT can range in duration from patient to patient and provider to provider. Although variability exists, the following table shows an example session-by-session outline.

• You are encouraged to think flexibly in determining length of treatment. Time-limited therapy may offer additional incentive for patients and therapists to work efficiently and effectively.

Brief CBT – Core Beliefs

Thought Skills… Discussion and Practice• Challenging Thoughts: Many times inaccurate thoughts

go unchallenged. They can be like a ‘Trojan Horse’ we believe them because they are inside our mind. Examining thoughts can lead to changing thoughts. • Accepting Thoughts: We can simply accept thoughts as

they are. Not fixing them but not in the words of ACT ‘fusing’ with them.

Thought Skills… Discussion and Practice

• Thought Stopping: We can use various skills to stop thoughts. The most simple of these is to simply using our inner voice to say ‘stop’ to an unhelpful thoughts.

• Distraction: Focusing on something other then a thought can allow the thoughts to stop and reduce their impact.

• Thought Replacement: We can replace a negative unhelpful thought with a more true and more helpful thought.

Exercise Teaching Thought Skills

Developing Balanced Thinking Thought Records

Downward Arrow Technique - Finding Core Beliefs

Case Conceptualization

Beck Video

CBT Session Overview

• The first 1/3 or 20 min: Is focused on assessing where a patient is, their concerns about tx and reviewing homework.

• The second 1/3 20 min: Is focused on introducing session topic and relating topic to patient’s life and symptoms.

• The third 1/3 20 min: Is focused on exploring patients understanding and reaction to interventions, developing home work and reviewing and addressing risk and challenges they may face in HW or in the week.

Adapting CBT Culturally Responsive Care

1. Assess Needs – The core task here is to identify culturally respectful behaviors. All cultures have indicators of respect both verbal and non-verbal. These are key factors for establishing the relationship and the “Collaborative Set.”

2. Identify culturally related strengths and supports – Pride in identity, Faith/Religion/Spirituality, Cultural Practices e.g. music/art/food/connections, Living Skills, Beliefs, Ways to Cope with discrimination and disconnection.

3. Environmental Problems – It is important to not place environmental problems as challenges to cognitively restructure. These situations can require acceptance, actions and engagement but do not need to be challenged.

Adapting CBT Culturally Responsive Care

4. Addressing Environmental/Systemic Problems – Adapt interventions to cultural realities, Make changes to minimize stressors, Increase personal stregnths and support, Work with microagressions, Build systems of support, Culturally congruent self-care.

5. Validate Reported Experiences of Oppression – It is important to start with validation and not argue or disagree. Assume the information being provided is accurate, validate their reactions and thoughts. After a person is understood provide time to explore effective ways to manage the impacts. Psychoeducation about micro-aggressions, problem solving for after a micro-aggression, and developing care plans.

6. Emphasize collaboration over confrontation - CBT often takes an active stance in challenging in-effective cognitions. When working across lines of differences developing a solid alliance and working form the collaborative set is likely to be more effective.

Adapting CBT Culturally Responsive Care

7. Restructuring Through Assessing ‘Helpfulness of Thought’ Vs ‘Validity of Thought’ – It is important to use the ability to reflect on the helpfulness of a thought or thinking style. The experience of being invalidated can be quite strong by saying a thought is ‘invalid’ it also makes the relationship more vulnerable to applying one’s own cultural beliefs over another’s.

8. Do not challenge core cultural beliefs – Cultures are wholisms. They work with a coherent interaction of beliefs and relationships. It is important to not challenge directly a core culturally held belife.

9. Base Helpful Cognitions in Core Cultural Strengths and Supports – If you root a movement towards ‘helpful’ cognitions in the core cultural strengths it can help support change and minimize risk of disconnections and culturally invalidating moments of disconnect.

ABCs of Change: A = Antecedents

Antecedents: Antecedents, or events that occur before a behavior, typically elicit emotional and physiological responses.

ABCs of Change: B = Behaviors

Behaviors: A behavior is anything the patient does, feels, or thinks immediately following the antecedent.

Questions to Assess (B)ehaviors

1. Right after ___ what do you feel?2. Right after ___ what sensations happen in your body?3. Right after ___ what thoughts happen?4. Right after ___ what do you have an urge to do?5. Right after ___ what do you do?

ABCs of Change: C = Consequences

Consequences: Consequences are categorized as being either positive or negative that maintain the behavior.

Assessment Using the Problem List

Culturally Responsive CBT Case Conceptualization• Step 1 – Assessing Concerns and Difficulties: It is important to understand what the

concerns and difficulties are. These factors should be included: 1. Screeners, 2. Problem List, 3. Cognitions, 4. Affect/Behavior/Physical, 5. ABC/Functional Assessment.

• Step 2 – Assessing Cultural Factors Impacting Treatment: Assessing core cultural factors impacting care is vital for adapting effective treatments. This includes: 1. Cultural Strengths/Support, 2. Indications of Respect, 3. Environmental/Systemic Problems, 4. Experiences of Oppression.

• Step 3 – Clinical Hypothesis and Treatment Plan: Once the understanding of the problems and cultural realities are assessed one can come up with a clinical hypothosis of what is creating and maintaining symptoms as well as what can help change.

• Step 4 – Identifying Possible Obsticals: Making a clear list of areas that might impact or create obsticals can improve care. This will include cultural factors, environmental factors, intrapsychic factors social factors health factors.

CBT Formulation…

Case Formulation Exercise