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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