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M. Katherine Shear, M.D. Professor of Psychiatry Columbia University School of Social Work Columbia University School of Physicians and Surgeons.

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Presentation on theme: "M. Katherine Shear, M.D. Professor of Psychiatry Columbia University School of Social Work Columbia University School of Physicians and Surgeons."— Presentation transcript:

1 M. Katherine Shear, M.D. Professor of Psychiatry Columbia University School of Social Work Columbia University School of Physicians and Surgeons

2 Woody Allen is still making movies, but the kind of psychotherapy he made famous -- lying on a couch, endlessly talking about your mother and your lousy childhood -- is losing its audience. Those who find themselves in a therapist's office these days are likely to encounter a very different form of treatment, one that's short-term, goal-oriented and evidence-based. It will probably involve sitting upright in a chair. A Change of Mind Thanks to Managed Care, Evidence-Based Medical Practice and Changing Ideas About Behavior, Cognitive Therapy Is the Talking Cure of the Moment By Cecilia Capuzzi Simon Special to The Washington Post Sept 3, 2002

3 Cognitive therapy is practiced around the world, taking hold in places from the Middle East to Japan. The technique has had its greatest acceptance in Great Britain, where it is widely used as a first-line treatment for depression, panic and obsessive-compulsive disorders, and in conjunction with medication to relieve symptoms of schizophrenia and manic depression. Capuzzi Simon The Washington Post 2002

4 WE WILL REVIEW SOME HIGHLIGHTS OF INTERVENTION RESEARCH OVER THE PAST DECADES AND WHERE WE ARE NOW

5 EDUCATION 1972 - Tufts University Medical College 1975 - internal medicine Mt. Sinai Hosp. 1976 - infectious disease fellowship MSH 1979 –psychiatry Payne Whitney Clinic 1980- psychosomatic fellowship Montefiore FACULTY POSITIONS 1980-1992 Cornell 1992-2006 –University of Pittsburgh 2006-present –Columbia NIMH FUNDING Panic Disorder 1983 R03MH3899 – CV reactivity 1988 R01 MH42430 – Efficacy of CBT Panic Disorder (cont.) 1989 R01 MH45964 – Multicenter Comparative Treatment Study 1993 R01 MH50902 – Psychological treatment 1995 R10 MH45964 – Panic Treatment study Health Services 1994 R24 MH53817 – RTGP – Treatment Effectiveness Studies in Women 1998 R24 MH56843 – Caring for Moms with children in MH treatment Complicated Grief 2000 R01 MH60783 – CG Treatment study 2007 R01 MH070741 – CGT for older adults 2008 R25MH084786 – TF-CBT training 2009 R01 MH60783 – Optimizing Treatment (multicenter study)

6 Goal of behavioral intervention research Defining the intervention target Conceptualizing intervention principles, strategies and procedures Establishing efficacy Achieving effective dissemination and implementation Complicated grief: A case example

7 To identify and describe useful, efficient ways to reduce suffering, improve well-being, and foster optimal functioning To determine how, to whom, where and when to deliver efficacious interventions in the community

8 Interventions can target behavioral, cognitive, social or emotional problems in an individual, family or group For example, intervention targets can be Known mental health problems, identified in the DSM (e.g. major depression) Symptomatic distress not identified in DSM (e.g. problem grief reactions) Negative health behaviors (e.g. use of chemical substances) Problematic interpersonal behaviors (e.g. interpersonal violence) Dysfunctional ways of thinking (e.g. delusions or hallucinations) Problems with emotion regulation (e.g. unified protocol) Family problems (e.g. dysfunctional families) Community problems (e.g. suicide rates) Intervention can focus on prevention, treatment or recurrence

9 Intervention development begins with understanding the problem Requires a period of library or laboratory research Underlying theory may exist or not – if not needs to be developed and to rest on empirical underpinnings Basic assumptions and principles form an important scaffold for effective intervention Assumptions derive from a theoretical model of the problem and its solution Principles derive from a model of how the target problem can change Strategies and procedures are the methods by which the intervention acts Clearly described, operationalized and manualized Guided by the underlying assumptions and principles Usually derived from previous research

10 After I graduated from the Psychoanalytic Institute, I was eager to validate the psychoanalytic concepts to make them more acceptable to the scientific community. As depression was the most frequent disorder in my practice, I decided to focus on that disorder. According to the then current psychoanalytic theory, the depressed individual experiences unconscious rage against other close persons but, as the rage is unacceptable, it is repressed and turned against the self. Beck AT Nature Medicine 2006

11 To his surprise, Beck discovered the opposite was true: dreams of depressives had less hostility than non-depressed control group Dream content of depressives (rejected, deserted, thwarted) similar to waking descriptions A model based on negative internal representations of self and others explained the symptoms Patients could be helped to evaluate the validity of these cognitive distortions and re-evaluation was associated with symptom resolution Beck AT Nature Medicine 12: 1139-1141 2006

12 12 Cognitions MoodBehaviors SCHEMA Events Schema-related Maladaptive Irrational Avoidant Other dysfunctional

13 Behavior Emotion Cognitive Appraisal Event Wright, Basco and Thase Learning Cognitive Behavioral Therapy

14 Rush et. al. Cognitive Ther Res. 1: 17-37 1977

15 Hollon et al. J Clin Psych 66:455-468, 2005 * Significant advantage for combined Rx.

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17 Developed from studies of treatment problems in depression studies ….a subgroup of depressed older adults were bereaved and exhibited symptoms that did not respond to standard efficacious treatment

18 1. Preoccupation with the person who died 2. Memories of the person who died are upsetting 3. The death is unacceptable 4. Longing for the person who died 5. Drawn to places and things associated with the person who died 6. Anger about the death 7. Disbelief 8. Feeling stunned or dazed 9. Difficulty trusting others 10. Difficulty caring about others 11. Avoidance of reminders of the person who died 12. Pain in the same area of the body 13. Feeling that life is empty 14. Hearing the voice of the person who died 15. Seeing the person who died 16. Feeling it is unfair to live when the other person has died 17. Bitter about the death 18. Envious of others 19. Lonely Rated 0 (never) – 4 (always) Score > 25 (30) defines CG Prigerson et al., 1995 SCORE > 30 IDENTIFIES A PROBLEMATIC GRIEF RESPONSE

19 http://www.google.com/search?hl=en&q=funeral+images MORE THAN 2.5 MILLION PEOPLE DIE EVERY YEAR IN THE UNITED STATES ON AVERAGE1-5 CLOSE FRIENDS AND RELATIVES ARE BEREAVED BY EACH DEATH ABOUT 7% OF BEREAVED PEOPLE DEVELOP COMPLICATED GRIEF

20 BEREAVEMENT: Experiencing the death of someone close GRIEF: the response to bereavement Acute grief – the early response that can be intense and all-encompassing, that heals over time Integrated grief – the permanent residual grief after healing occurs Complicated grief – a lasting form of acute grief that does not heal MOURNING: the psychological healing processes set in motion by bereavement aimed at acknowledging the finality and consequences of the loss and re-envisioning life without the deceased person

21 21 Question: Who are the people to whom we are closest? Answer: Attachment relationships - those people To whom we seek proximity and from whom we resist separation. With whom we share Support and reassurance (safe haven function) Pleasure and confidence in competence (secure base function) Among adults, caregiving is at least as important as being cared for Hofer M Monogr Soc Res Child Dev, 59, 192–207; Antonucci et al 2004; Feeney J Pers Soc Psych 631 -648 2004; Hazan and Ziefinan Cassidy & P. R. Shaver (Eds.), Handbook of attachment (pp. 336–354) New York: Guilford Press. 1999

22 ADULT ATTACHMENT RELATIONSHIPS OCCUR IN MANY SPECIES

23 The underpinning of attachment behavior is a biobehavioral motivational system, closely linked to motivational systems for exploration and caregiving. Mikulincer, et.al., 2002; Mikulincer, et.al., 2003; Pereg & Mikulincer, 2004; Collins & Feeney, 2004 Like other animals, we are biologically programmed to seek, form and maintain close attachment relationships…. and to resist separation from these individuals Biobehavioral motivational systems are guided by brain circuitry that is linked to both positive (reward) and negative affect centers as well as cognitive systems for memory and planning These systems operate across the lifespan using similar processes for maternal-infant and adult romantic relationship, though adult systems are more mature and complex Suryia the organutan and Roscoe the hound

24 Mastery and performance success Learning and performing Relationships with others Cognitive functioning Coping skills and problem solving Self esteem Emotion regulation Sleep quality Pain intensity (physical and social) http://www.suryiaandroscoe.com/ On average, people have 1-5 attachment relationships at any given time Bell & Ainsworth, 1972; Grossmann, et.al., 1999; Cassidy, 1999; Carmichael and Reis 2005; Roisman 2005; Kim et al 2008; Mikulincer, et.al., 2002; Mikulincer, et.al., 2003; Pereg & Mikulincer, 2004; Collins & Feeney, 2004; Antonucci et al 2004 Bereavement results in loss of regulatory functions

25 Recurrent pangs of sadness and yearning A mix of other emotions, both positive and negative Preoccupying thoughts and memories of the deceased Behavioral tendencies to seek proximity or avoid reminders of the deceased Sense of disconnection from ongoing life, feelings of incompetence

26 Each persons grief follows a unique trajectory, guided by circumstances of the death characteristics of the bereaved person and her/his relationship to the deceased consequences of the loss context in which the bereaved person mourns It is a tribute to the human spirit that most people weather the storm of loss, often absorbing this most unwanted reality in a way that deepens their humanity and opens their hearts to the suffering of others. Grief is both universal and unique to each bereaved person and each lost relationship.

27 1. Bereavement is a universal experience 2. Grief comprises a recognizable group of symptoms 3. Because loss is forever, there is a lasting form of grief even after acute grief heals 4. Bereavement sets in motion a natural healing process 5. Healing acute grief requires a sufficiently supportive environmental context

28 Our closest relationships are intrinsically rewarding, provide a foundation of security and shared competence, and contribute to physiological and emotional regulation Brain circuitry, sometimes called internal working models, contains information about our close relationships, that includes implicit and explicit memory, positive and negative emotion centers and cognitive monitoring, evaluation and planning processes Healing after bereavement entails learning and emotion regulation

29 1. We need to understand close relationships in order to understand the effects of their loss 2. Grief symptoms are generated by brain systems entailed in close attachments, e.g. separation response, caregiver self-blame, inhibition of exploratory system 3. Loss is permanent and grief must be integrated so that its intensity and dominance recedes and no longer disrupts ongoing life 4. The natural healing process entails learning and emotion regulation 5. The optimal context for adaptive healing includes support from others who offer a balance of soothing comfort and gentle encouragement to re-engage in ongoing life

30 The healing process by which information about the loss is fully acknowledged, its consequences considered and assimilated into the working model and future goals and plans redefined, i.e. a learning process Effective mourning entails emotion regulation in which Attention typically oscillates between confronting the painful information and turning away (defensive exclusion) There are periods of positive emotions Typically takes place in a social context; companionship fosters learning and emotion regulation Progress occurs in fits and starts, that are not predictable or controllable and may not be noticeable as it occurs 30 Bowlby Loss Basic Books 1980

31 Rumination about circumstances or consequences of the loss; the if onlys (counterfactual thinking) Dysfunctional behaviors, e.g. extensive, prolonged avoidance, compulsive proximity seeking, use of substances, negative health behaviors Ineffective emotion regulation, e.g. over or under-engagement with emotional stimuli, deficiency of positive emotions, physiological dysregulation (e.g. sleep or daily rhythm disturbance) Social-environmental neglect or toxicity e.g. absence of a close companion (inadequate support) and/or interpersonal toxicity (hostile, aggressive, blaming behavior) or serious external issues Boelen PA et al. (2003), Boelen PA et al. (2006), Shear K et al. 2007; Shear K et al., unpublished data

32 Persistent yearning, longing, searching; despairing sadness, other troubling emotions Preoccupation with thoughts and memories of the deceased; dysfunctional thoughts Intense reactivity to reminders and avoidance Feeling life has no purpose, meaning, joy or satisfaction Acute Grief Does not progress COMPLICATED GRIEF Information about the death is not processed, due to Rumination Avoidance Ineffective emotion regulation Acute grief symptoms are intense and unchanging Attachment activation persists Inhibition of exploration continues

33 BEREAVEMENT Acute grief symptoms Integrated grief Treatment Targets Grief complications Natural healing Resolve Facilitate

34 Dysfunctional thoughts Cognitive therapy strategies used in Grief monitoring Revisiting exercise and debriefing Imaginal conversation Excessive avoidance Exposure strategies Imaginal revisiting Situational revisiting Improve emotion regulation using strategies associated with natural healing Ineffective emotion regulation Absence of adequate companionship Provide and encourage companionship Companionship alliance Meeting with significant other

35 Learn about the death in explicit and implicit memory systems Utilize effective emotion regulation strategies Loss and restoration-related problems addressed in tandem Supportive companionship Progress may not be easily observable Encourage confrontation with relevant information about the death (revisiting) Foster emotion regulation Oscillation between pain and respite Self care, rewards, personal goals to foster positive emotions Acceptance, reappraisal, problem-solving Encourage coping with loss and restoration- related problems in tandem Provide and encourage companionship Use strategies for review of progress 35

36 In the process of receiving and evaluating information that stems from major change of any sort a secure person habitually seeks the help of a companion… to negate or verify information, to confirm or disconfirm initial evaluations, to help consider how and why the event should have occurred, what its further implications may be, what the future may hold, and what plans of action, if any, may be appropriate. By acting also as an attachment figure and caregiver the companion may perform an even greater service. For by this very presence, the bereaveds anxiety is reduced, his morale fortified, his evaluations made less hastily, and the actions taken to meet a situation selected and planned more judiciously. Bowlby Loss p.232

37 1. Effective companionship is important in healing after loss 2. Structure is helpful to people experiencing acute grief 3. Positive emotions are physically and emotionally healthy and foster optimal creativity and problem solving 4. Self observation and reflection, are important tools for both addressing complications and facilitating natural healing 5. Natural healing is facilitated by addressing loss and restoration- related problems in tandem, and oscillating between pain and respite 6. Imagery fosters implicit learning and emotion activation

38 Grief monitoring Imaginal revisiting Situational revisiting Memories and pictures Imaginal conversation Grief monitoring Aspirations and plans Self care and positive emotions Situational revisiting Loss-focused Restoration-focused Comfort and help from others Self-observation and reflection Structure

39 INTRODUCTORY PHASE: THE FOUNDATION Develop a solid working alliance (safety, mutual goals and expectations) Understand the persons life history, interpersonal world and the place of bereavement within this context Begin grief monitoring, weekly plans and personal aspirations/ goals work Provide the bereaved person and a significant other with information and orientation to the treatment MIDDLE PHASE: THE HEART OF THE TREATMENT Loss Focus: Imaginal revisiting of the death, situational revisiting, memories and pictures, imaginal conversation Restoration Focus: problem solving, aspirations and plans, self care, re-engaging with others TERMINATION PHASE: TRANSITION TO ONGOING LIFE Summarize gains and plan for the future Process thoughts and emotions about ending

40 chi-square=7.56, df=1, p =0.006chi-square=5.07, df=1, p <0.024 NNT: Completers: 3 ITT: 4 Shear et al JAMA 293:2601 2005

41 Who does the treatment help? Are there moderators? Gender? Culture? Symptoms? Context? Who can do the treatment? What training is needed? Professionals? With or without extensive training and supervision? Lay people? Self-administration

42 How can it be administered most efficiently? What mediates the treatment effects? What are the principles of change? What are active agents- what procedures are needed? Is there moderated mediation (e.g. some people require a given procedure and others dont? What level of fidelity is required? What comprises adherence? Competence?

43 Currently being used in Canada, Ireland, Norway, Japan and China Japanese have completed pilot studies of efficacy in people suffering violent loss Japanese have plans for modifying CG to use in tsunami survivors We will develop a collaborative project using the basic assumptions and principles from CGT to design a culturally relevant intervention for tsunami survivors with CG Social Work Ph.D. Candidate in Utah has completed a pilot RCT of group CGT showing significantly greater improvement in CGGT than treatment as usual (K Supiano personal communication) Anecdotal reports from clinicians across the country report successful implementation of CGT Clinicians at Kaiser Permanente in San Diego and at a military base in Canada have attended workshops and are using the principles and procedures in daily practice. Plans are underway to utilize CGT assumptions and principles to educate palliative care clinicians and funeral directors

44 Behavioral intervention research is in its fifth decade and has matured significantly It is now clear that it is possible to devise helpful interventions, document their efficacy and disseminate these interventions effectively We are beginning to learn how to identify moderators and mediators of intervention effects in order to further improve them The progress is very heartening, but…

45 We would be wise to remember the principal lesson coming down to us from the 1960s. Behavior therapy is not a school of psychotherapy, nor does it reflect some unified worldview of human nature. Rather, behavior therapy is the application of the principles of cognitive behavioral science to human problems and, as such, reflects the never- ending quest of the human race to better itself through the use of human reason and the methods of science. And we have miles to go before we sleep. Barlow Promises to Keep Behav. Tx 28:589 1997


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