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From Symptom to Solution: a brief, 3 step protocol for CBT Paul Rijnders Clinical Psychologist Indigo Zeeland, The Netherlands (www.kortdurendetherapie.nl)

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Presentation on theme: "From Symptom to Solution: a brief, 3 step protocol for CBT Paul Rijnders Clinical Psychologist Indigo Zeeland, The Netherlands (www.kortdurendetherapie.nl)"— Presentation transcript:

1 From Symptom to Solution: a brief, 3 step protocol for CBT Paul Rijnders Clinical Psychologist Indigo Zeeland, The Netherlands (www.kortdurendetherapie.nl) 2011

2 Brief CBT: motives Unbalance demand and supply Changing expectations Costs Negative image High threshold

3 Brief CBT: requirements Low threshold Plain case concept Easy to transfer / to learn Enhancing commitment / Self-Directedness Long lasting

4 Questions How many people suffer from serious mental problems? % Which percentage of this group receives professional mental health treatment? between 25% and 55% ( differs per country)

5 Question What works in CBT ?

6 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)

7 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?)

8 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

9 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)

10 Measurement 0: OQ – 45. -Severity -Global functioning -Risk - factors “psychological thermometer” TCI - sf -Traits / coping style -Strenghts and weaknessess -habits -equilibrium

11 Questionaires: (OQ-45) Gegevens van patiënte Geboortedatum: 1978 Geslacht: Vrouw Behandellocatie: Oosterschelderegio Behandelfase: nog geen of 1 gesprek gehad Testdatum: OQ45-score: 75. Sub-schales Symptom Distress: 51 This score is high Interpersonal relations: 10 This score is normal Sociale Rol: 14 This score is above average Critical Items Suicide: Yes Substance abuse: No Violaence: Yes Er is een hoge factorlading op Depression/anxiety: Yes Feeling of Well-being: Yes Impact of Stress: Yes

12 “the psychological thermometer” Gegevens van patiënte Geboortedatum: 1978 Geslacht: Vrouw Behandellocatie: Oosterschelderegio Behandelfase: nog geen of 1 gesprek gehad Testdatum: OQ45-score: 75.. Sub-schales Symptom distress: 51: H Interpersonal relations: 10 : N Social Roles: 14 :above A Critical Items Suicide: yes Substance abuse: No Violence: Yes Er is een hoge factorlading op Depression/anxiety: Yes Feeling of Well-being: Yes Impact of Stress: Yes

13 Your psychological temperature Gegevens van patiënte Geboortedatum: 1978 Geslacht: Vrouw Behandellocatie: Oosterschelderegio Behandelfase: nog geen of 1 gesprek gehad Testdatum: OQ45-score: 75. Deze score is hoog. Sub-schalen Symptom distress: 51 H. Interpersonal relations: 10 N. Social Roles: 14 above A Critical Items Suicide: Yes Substnce abuse: No Violence: Yes Er is een hoge factorlading op Depression/anxiety: Yes Feeling of Well-being: Yes Impact of Stress: Yes

14 Step I, Sub-step 1: Restoring overview Dialogue Patient’s report Measurement Manageable bits

15 descriptionl Symptom distress (Sd) Circumstances (Ci). Coping style (Cs) “habits” Sd – Ci - Cs - outline

16 descriptionl 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

17 Step I, substep 2: connection Sd = Ci x Cs Descriptive diagnosis Emphasis on: Cs

18 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

19 Trait and Character Inventory LowBelow average NormalAbove average High NS X HA X RD X P X SD X C X ST X

20 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

21 Measurement 1.: evaluate and (if necessary) adjust OQ- 45Which changes ? RC index: 12 TCI -sfWhich changes?

22 Step II: Behaviour Change

23 Social learning Cognitive restructuring Behaviour experiments

24 Step II, Sub-step 4: Habits and alternatives Sd = Ci x Cs

25 Step II, Sub-step 4: Habits and alternatives Sd = Ci x Cs

26 Coping style Habits Dimensional Position on an equilibrium too little too much

27 Cs: equilibrium Egoist Altruist Avoidant Impulsive Pessimist Optimist Extravert Introvert

28 Cs: equilibrium: other examples Richard Hyacinth Manuel Basil Florance Nightingale Madonna Throwing in the towel Man of action

29 Habits and alternatives: intermediates Avoidant—cautious—steady—carefree—enthousiatic— Impulsive. Shy—introvert—single—normal—cooperative— extravert—Sociable. Obsessive—stubborn—serious—steady—flexible— Indolent.

30 Step II, sub step 5: Behaviour change by imitation The 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

31 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

32 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…?”

33 Equilibrium and techniques Observing (oneself, other people, exceptions, effects) Reflecting Imitating Experimenting / role playing Cognitions

34 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.

35 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

36 Step II, sub step 7 gedachten uitdagen FeelingsSituationAutomatic 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?

37 measurement 2: Evaluate and what next OQ- 45Which changes Evaluation How to keep the benefits / changes/ ameliorations TCI.-sfWhich changes Evaluation How to keep the benefits

38 Step III, sub step 8 Termination and relapse prevention Reminders Peers Symptom = signal Time out Instruction booklet

39 Evidences

40 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

41 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

42 Evidence 3 Heene et al,

43 Heene et al 2011

44 Severity at start OQ-45. Total scoreAt 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)

45 time ,00 80,00 60,00 40,00 very high high mild low OQ_Total_group OQ-45.2-Total Means

46 Conclusion Guided/shared exploration and planning + Guided SL, BE and CR + Low threshold (at least) same result but in shorter time

47


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