from symptom to solution: a brief, 3 step protocol for cbt

From Symptom to Solution:a brief, 3 step protocol for CBT

Paul RijndersClinical Psychologist

Indigo Zeeland, The Netherlands

(www.kortdurendetherapie.nl)

2011

Brief CBT: motives

• Unbalance demand and supply

• Changing expectations

• Costs

• Negative image

• High threshold

Brief CBT: requirements

• Low threshold

• Plain case concept

• Easy to transfer / to learn

• Enhancing commitment / Self-Directedness

• Long lasting

Questions

• How many people suffer from serious mental problems?

7 - 8 %

• Which percentage of this group receives professional mental health treatment?

between 25% and 55% (differs per country)

Question

What works in CBT ?

What works in CBT?

• Cognitive restructuring

• Behaviour experiments / activation

• Shared Decision Making (targets and pathways)

(helping patients to become aware of their strenghts and weaknesses and to convert weaknesses into power)

3 Steps

• Shared Problem Definition (S.P.D)(emphasis on coping style / (discouraging) habits)

• Behaviour Change (B.Ch)(learning to improve coping style by observing, comparing, reflecting, imitating and experimenting)

• Relapse Prevention (R.Pr)(what triggers? How to anticipate?)

3 steps, 8 sub-steps

• SPD : - Restoring overview

- Finding connection

- Formulating targets / treatmentplan

• BCh : - Habits + alternatives

- Behaviour change by imitation / social learning

- The power of thoughts

- Challenging of thoughts

• RPr : - Termination and relapse prevention

3 steps, 8 sub-steps, 4 measurements

M. 0

• SPD: - Restoring overview

- Finding connection - Formulating targets / treatmentplan

M. 1

• BCh: - Habits + alternatives

- Behaviour change by imitation / social learning - The power of thoughts - Challenging of thoughts

M. 2

• RPr: - Termination and Relapse Prevention

M.3 (after 4 months)

Measurement 0:

OQ – 45.-Severity-Global functioning-Risk - factors

“psychological

thermometer”

TCI - sf-Traits / coping style

-Strenghts and

weaknessess

-habits-equilibrium

Questionaires: (OQ-45)

• Gegevens van patiënteGeboortedatum: 1978 Geslacht: VrouwBehandellocatie: OosterschelderegioBehandelfase: nog geen of 1 gesprek gehadTestdatum: 23-02-2010

------------------------------------

OQ45-score: 75.

Sub-schalesSymptom Distress: 51 This score is highInterpersonal relations: 10 This score is normal Sociale Rol: 14 This score is above average

Critical ItemsSuicide: Yes Substance abuse: No Violaence: Yes

Er is een hoge factorlading opDepression/anxiety: YesFeeling of Well-being: YesImpact of Stress: Yes

“the psychological thermometer”

• Gegevens van patiënteGeboortedatum: 1978 Geslacht: VrouwBehandellocatie: OosterschelderegioBehandelfase: nog geen of 1 gesprek gehadTestdatum: 23-02-2010

------------------------------------

OQ45-score: 75. .

Sub-schalesSymptom distress: 51: H Interpersonal relations: 10 : N Social Roles: 14 :above A

Critical ItemsSuicide: yes Substance abuse: No Violence: Yes

Er is een hoge factorlading opDepression/anxiety: YesFeeling of Well-being: YesImpact of Stress: Yes

180

87

55

0

Your psychological temperature

• Gegevens van patiënteGeboortedatum: 1978 Geslacht: VrouwBehandellocatie: OosterschelderegioBehandelfase: nog geen of 1 gesprek gehadTestdatum: 23-02-2010

------------------------------------

OQ45-score: 75. Deze score is hoog.

Sub-schalenSymptom distress: 51 H. Interpersonal relations: 10 N. Social Roles: 14 above A

Critical ItemsSuicide: Yes Substnce abuse: No Violence: Yes

Er is een hoge factorlading opDepression/anxiety: YesFeeling of Well-being: YesImpact of Stress: Yes

180

87

55

0

75

Step I, Sub-step 1: Restoring overview

• Dialogue• Patient’s report • Measurement

Manageable bits

description l

Symptom distress (Sd)

Circumstances (Ci)

.

Coping style (Cs)

“habits”

Sd – Ci - Cs - outline

description l

Symptom distress (Sd) Sleeplessness

Anxious

Retreat / shrink into oneself

Circumstances (Ci)

.

Father passsed away

Change work

Quarrel in family

4 kids

Support from husband

Coping style (Cs)

“habits”

High sense of responsibility

Careful / caring

Self-sacrificing

Neglects herself

Sd – Ci - Cs - outline

Step I, substep 2:

connection

Sd = Ci x Cs

• Descriptive diagnosis

• Emphasis on: Cs

Step I, Sub-step 2

example

Sd = Ci x Cs

• Depression = (too) much burden x doom-mongering

• Panic D = loss x doubtfulness

• Panic D = > distress x extreme cautious

Trait and Character Inventory

Low Below average

Normal Above

average

High

NS X

HA X

RD X

P X

SD X

C X

ST X

Step I, Sub-step 3:

Targets; Pathway

• Sd: self- control techniques; medication

• Ci: support; relationship(s); sharing the burden

• Cs: improving coping style; equilibrium; prototypes; metaphor

Measurement 1.: evaluate and (if necessary) adjust

OQ- 45 Which changes ?

RC index: 12

TCI -sf Which changes?

Step II: Behaviour Change

Step II: Behaviour Change

• Social learning

• Cognitive restructuring

• Behaviour experiments

Step II, Sub-step 4:

Habits and alternatives

Sd = Ci x Cs

Step II, Sub-step 4:

Habits and alternatives

Sd = Ci x Cs

Coping style

• Habits• Dimensional • Position on an equilibrium

too little----------------------------------too much

Cs: equilibrium

• Egoist-----------------------------------Altruist

• Avoidant--------------------------------Impulsive

• Pessimist------------------------------Optimist

• Extravert-------------------------------Introvert

Cs: equilibrium: other examples

• Richard-----------------------------------Hyacinth

• Manuel------------------------------------Basil

• Florance Nightingale------------------Madonna

• Throwing in the towel ------- Man of action

Habits and alternatives: intermediates

• Avoidant—cautious—steady—carefree—enthousiatic—Impulsive.

• Shy—introvert—single—normal—cooperative—extravert—Sociable.

• Obsessive—stubborn—serious—steady—flexible—Indolent.

Step II, sub step 5:

Behaviour change by imitationThe use of prototypes and metaphors

• Too much “Manuel – like” behaviour (Fawlty Towers)

• Too much “Richard”, too little “Hyacinth or Onslow”

• Too much Florance N, too little Madonna

• From: “always yes, of course” to: “yes, but”

• From Florance N. to: “in between”

• From: “absolute single” to: “ a little cooperation”

• From: throwing in the towel to: deliberated action

• From: bull in China shop to: deliberated action

The power of metaphor / prototype

• Multiple access (verbal; imaginative; interactive; activity)

• Differs perception and reality (activates distance)

• Humor (nonblaming)

• Examples for change (perspective)

• Speedy recall

Behaviour change by imitation:techniques

• Equilibrium and sociogram “if you imagine……(family, friends, collegues, etc), how

are they divided on...”

• Equilibrium and prototypes “Who among your collegues, acts different than

Florance Nightingale, without going overboard…?”

Equilibrium and techniques

• Observing (oneself, other people, exceptions, effects)

• Reflecting

• Imitating

• Experimenting / role playing

• Cognitions

Step II, sub step 6: The interconnection between behaviour and Cognitions / automatic ideas

• Simple examples: (a sudden noise at night).

• Burglar or cat? (action guided by perspective)

• How would Florance N. react / think about that noise? How would Madonna do? Or …?

• Simple role playing in the office.

Cognitions and your equilibrium

• Stimulate meta cognitive activity: if it is your habit to act like, and you realise that …… what do you think that your habitual thoughts will be about ……….

• Introduce The Beck outline

Step II, sub step 7

gedachten uitdagen

Feelings Situation Automatic ideas about what happend

How realistic are they ?

Realistic ideas

Result

Sd

increases

What happened / could provoke these feelings

How did you evaluate what happened

If you take some time and reflect, what comes up to your mind

Which alternatives seem tot be more realistic

What is the effect on your feelings / actions?

measurement 2:

Evaluate and what next

OQ- 45 Which changes

Evaluation

How to keep the benefits / changes/ ameliorations

TCI.-sf Which changes

Evaluation

How to keep the benefits

Step III, sub step 8

Termination and relapse prevention

• Reminders

• Peers

• Symptom = signal

• Time out

• Instruction booklet

Evidences

Evidence 1.

Van Orden et al (2009) Psychiatric Practice

• 165 patients, different diagnoses• Brief therapy (BT) at GP’s office versus CAU in second line

• Symptom reduction: No difference• Quality of life: No difference• Satisfaction: No difference

• Needed amount of sessions: BT: 30% less.• % Relapse: not available yet

Evidence 2

Van Straten et al. (2006, Br. Journ. Psych.; 2006, Acta Ps. Scandinavica)

• 702 patients: Anxiety / mood disorders• Random: BT – CBT or CAU

• Results: same as: Van Orden

• Relapse (18-24 m): CAU >> CBT > BT

Evidence 3

Heene et al,

Heene et al 2011

Severity at start

OQ-45. Total score At start (percentage)

Normal ( ≤ 54) 175 (18.2)

Above average (55 – 71) 259 (26.8)

High (72 – 87) 240 ( 24.9)

Very high ( ≥ 88) 290 ( 30.1)

time

321

100,00

80,00

60,00

40,00

very high

high

mild

low

OQ_Total_group

OQ-45.2-Total Means

Conclusion

• Guided/shared exploration and planning +• Guided SL, BE and CR +• Low threshold

• (at least) same result but in shorter time