2. Introduction to Cognitive Behavioural Therapy in the Treatment of Anxiety Disorders Dr Tim Dunne Consultant/Registered Clinical Psychologist Webster University, Geneva 5 th & 6 th November 2010 www.carlowpsychology.iewww.carlowpsychology.ie © www.carlowpsychology.ie

3. 5 th November Introduction to the workshop Introduction to the workshop Expectations & Ground Rules Expectations & Ground Rules Outline & Structure of Workshop Outline & Structure of Workshop Nature & Types of Anxiety Healthy V. Clinical Anxiety Nature & Types of Anxiety Healthy V. Clinical Anxiety Anxieties related to Existential issues & Life Stage Transitions Anxieties related to Existential issues & Life Stage Transitions Medical Conditions & Anxiety Medical Conditions & Anxiety The Triune Brain The Triune Brain Importance of Breakfast Importance of Breakfast  Case Study

4. 6 th November Therapeutic Universals of Treatment Therapeutic Universals of Treatment Factors Determining Outcome in Therapy Factors Determining Outcome in Therapy Therapist/Patient Differences in Expectations Therapist/Patient Differences in Expectations Core Concepts of CBT Treatment approach Core Concepts of CBT Treatment approach Development of CBT Development of CBT Language & CBT Language & CBT Resource Building Case Formulation in CBT & Case Study CBT & Treatment of Anxiety, Panic Disorder & Phobias CBT Treatment of Life Stage. Existential & Health Anxieties Treatment of PTSD  Workshop Conclusion & Evaluation

5. Terminology Patient – comes from the Latin “Patiens” which means “one who endures” Patient – comes from the Latin “Patiens” which means “one who endures” Client – means putting oneself under the protection of a patron Client – means putting oneself under the protection of a patron “Courage is resistance to fear, mastery of fear, not absence of fear” – Mark Twain “Courage is resistance to fear, mastery of fear, not absence of fear” – Mark Twain

6. General Points about Anxiety: Salkovskis (2008) Anxiety is normal Anxiety is normal Feelings of Anxiety are normal under threat Feelings of Anxiety are normal under threat Physical changes are a normal part of the Anxiety response Physical changes are a normal part of the Anxiety response Avoidance & Escape to safety are normal reactions to Anxiety Avoidance & Escape to safety are normal reactions to Anxiety Anxiety only becomes a clinical problem when it is severe & persistent  Anxiety disorders are exaggerations of normal emotional reactions not an “inherited brain disease”

7. General Points about Anxiety: Arden (2009, 2010) We’re hard-wired as a species for Anxiety We’re hard-wired as a species for Anxiety More than 25% of population suffer from Anxiety More than 25% of population suffer from Anxiety Core feeling in Anxiety is fear but can also be concern, worry, apprehension, panic, terror – gradations of Anxiety & metrics Core feeling in Anxiety is fear but can also be concern, worry, apprehension, panic, terror – gradations of Anxiety & metrics Never promise to get rid of patients’ anxiety rather to learn to cope & manage it more effectively Never promise to get rid of patients’ anxiety rather to learn to cope & manage it more effectively Distinguish between Healthy Anxiety which is a normal response to an challenging situation (eg) exams, interviews, public speaking etc Distinguish between Healthy Anxiety which is a normal response to an challenging situation (eg) exams, interviews, public speaking etc Fear-based memories encoded in the amygdala are highly resistant to forgetting In Panic = escalating anticipation that something terrible is happening In GAD = fear is more free floating that something is not quite right In PTSD = fear is episodic, acute, associated with flashbacks & triggers In OCD = fear is that catastrophe is about to happen & can be forestalled by rituals or checking  In Phobias = fear is associated with situations, sensations or animals or objects

8. Types of Anxiety Anxiety Disorder/GAD Anxiety Disorder/GAD Panic Disorder/Phobias Panic Disorder/Phobias Obsessive-Compulsive Disorder (OCD) Obsessive-Compulsive Disorder (OCD) Health Anxiety Health Anxiety Social Anxiety Post Traumatic Stress Disorder (PTSD) Existential/Bereavement Anxiety  Life Stage Development Anxiety

9. GAD Symptoms include having trouble relaxing, easily startled, poor concentration, muscle tension, sleep problems, headaches Symptoms include having trouble relaxing, easily startled, poor concentration, muscle tension, sleep problems, headaches Twice as many women suffer GAD as men Twice as many women suffer GAD as men Onset from middle childhood on Onset from middle childhood on Chronic condition with situational triggers Chronic condition with situational triggers Perfectionistic Standards “Musturbation” (Ellis) Rigidity Control obsession Treatment = CBT/ Psychoeducation/ Relaxation/  Prognosis = guarded

10. Panic Disorder Symptoms = Pounding heart, sweating profusely, nausea, dizziness, weak knees, frequency, dry mouth, feeling out of control etc Symptoms = Pounding heart, sweating profusely, nausea, dizziness, weak knees, frequency, dry mouth, feeling out of control etc 3% of population (USA) 3% of population (USA) Age of onset = 24 yrs Age of onset = 24 yrs Treatment = CBT Treatment = CBT  Prognosis is good

11. OCD Symptoms = Checking behaviour, Excessive hand-washing, rituals, hoarding etc Symptoms = Checking behaviour, Excessive hand-washing, rituals, hoarding etc Age of onset = 19 yrs Age of onset = 19 yrs 1% of population (USA) 1% of population (USA) Treatment = CBT & SSRIs Treatment = CBT & SSRIs Prognosis is guarded Prognosis is guarded High relapse rate High relapse rate  ? More sinister psychopathology underneath

12. Phobias Irrational fears of specific objects, places or situations Irrational fears of specific objects, places or situations Multiple types of Phobias Multiple types of Phobias Age of onset = childhood on Age of onset = childhood on 9% of population (USA) 9% of population (USA) Treatment = Desensitization & anxiolytics Treatment = Desensitization & anxiolytics Prognosis = good Prognosis = good  Can be Trauma element in genesis

13. Health Anxiety Constant fear about health issues or medical investigations despite negative tests & reassurance from doctors – hypochondria Constant fear about health issues or medical investigations despite negative tests & reassurance from doctors – hypochondria Tend to interpret normal body changes as signs of illness Tend to interpret normal body changes as signs of illness “I scarce ever read the account of any disease that I did not fancy myself afflicted with” – Joseph Addison (1672-1719) “I scarce ever read the account of any disease that I did not fancy myself afflicted with” – Joseph Addison (1672-1719) May include Body Image/Body Dysmorphia May include Body Image/Body Dysmorphia 3% of GP Consultations 3% of GP Consultations No gender differences/ Adult onset No gender differences/ Adult onset Children can have HA about their parents’ health Children can have HA about their parents’ health Treatment = CBT/ SSRIs/Anxiolytics Treatment = CBT/ SSRIs/Anxiolytics  Prognosis = guarded

14. Health Anxiety : 7 Types (Blenkiron, 2010) The Competitor – “Mine is much worse than other cases” The Loner – Consults GP for a chat to fill the gap in her life The Emergency – Out of hours crisis, no professional dares refuse an urgent consultation The Litigator – If something is wrong, then I’ll see you in court The Proxy – Devotes her life to presenting her child’s/partner’s or friend’s symptoms as a cover for own problems The Eccentric – Internet downloads on alternative therapies and spends large amounts on natural cures for which there is no evidence The Flatterer – Focus on those in training or very junior “You're the only one I can talk to/who has ever understood me” which may be true as the other professionals are tired of seeing her

15. Social Anxiety Fear of social situations or meeting people Fear of social situations or meeting people Very common Very common Age of onset = 13 or earlier Age of onset = 13 or earlier 7% of population meet DSM/ICD-9 criteria 7% of population meet DSM/ICD-9 criteria Treatment = Supportive/ Exposure/ Feedback/Self-Esteem work/ Social Skills Development Treatment = Supportive/ Exposure/ Feedback/Self-Esteem work/ Social Skills Development  Prognosis = good

16. PTSD Witnessing, experiencing Traumatic events which are life-threatening Witnessing, experiencing Traumatic events which are life-threatening Affects both children & adults Affects both children & adults Symptoms = numbness, nightmares, flashbacks, reliving, avoidance, social withdrawal, irritability, concentration & sleep difficulties, sense of foreshortened future Symptoms = numbness, nightmares, flashbacks, reliving, avoidance, social withdrawal, irritability, concentration & sleep difficulties, sense of foreshortened future Treatment = TFCBT, EMDR & SSRIs Treatment = TFCBT, EMDR & SSRIs NB = Relaxation Therapy & Non-Directive Therapy are contra-indicated (NICE, 2006) NB = Relaxation Therapy & Non-Directive Therapy are contra-indicated (NICE, 2006)  Prognosis = excellent for single event T

17. Existential/Bereavement Anxiety Anxiety/Panic associated with issues relating to Death, Existence or Meaning of Life Anxiety/Panic associated with issues relating to Death, Existence or Meaning of Life Meaning making Meaning making No Gender differences No Gender differences Age of onset = Teenage yrs on Age of onset = Teenage yrs on Universal at different Life Stages but particularly Mid- Life Universal at different Life Stages but particularly Mid- Life Key Life Questions arise – Who will I be? Who am I? or Who was I? Key Life Questions arise – Who will I be? Who am I? or Who was I?  Treatment = Supportive/Exploratory/ Logotherapy/ Existential Therapy

18. The Triune Brain (McLean, 1990) – One Mind, Three Brains

19. Medical Conditions & Anxiety Mitral Valve Prolapse occurs in 5 – 15% of General Population Mitral Valve Prolapse occurs in 5 – 15% of General Population Symptoms include chest pains, breathlessness and palpitations – symptoms common in GAD Symptoms include chest pains, breathlessness and palpitations – symptoms common in GAD Other conditions include: Adrenal Tumours Cushing’s Disease Hypoglycaemia Hypothyroidism Meniere's Disease Parathyroid disease  Post concussion

20. Medical Conditions & Anxiety Anxiety symptoms can also arise from metabolic and toxic effects of consuming or being exposed to chemicals or compounds such as mercury, carbon dioxide, barbiturates, benzodiazepines, Alcohol withdrawal, and deficiencies in magnesium, vitamin B12, potassium & calcium Anxiety symptoms can also arise from metabolic and toxic effects of consuming or being exposed to chemicals or compounds such as mercury, carbon dioxide, barbiturates, benzodiazepines, Alcohol withdrawal, and deficiencies in magnesium, vitamin B12, potassium & calcium Also asthma medications, nasal decongestant sprays, many decongestants, steroids & caffeine Also asthma medications, nasal decongestant sprays, many decongestants, steroids & caffeine  Some diabetics with hypoglycaemia may be unaware that their anxiety symptoms are the result of low blood sugar

21. Breakfast Skipping Breakfast contributes to – Skipping Breakfast contributes to – Problem Solving Working memory Attention span ConcentrationEnergy Mood Swings Stress Reactivity AnxietyDepression

22. Blood Sugar levels Blood sugar levels below 0.5mgs per Mllltr can lead to symptoms such as- Blood sugar levels below 0.5mgs per Mllltr can lead to symptoms such as- Free floating anxiety Free floating anxiety Shakiness Shakiness Light-headedness Light-headedness Irritability Irritability Rapid Heartbeat Rapid Heartbeat  Concentration difficulties

23. Nutrition After Breakfast, the food is absorbed in your gastrointestinal tract After Breakfast, the food is absorbed in your gastrointestinal tract Amino acids & other nutrients such as vitamins & minerals are carried thru the bloodstream to your brain Amino acids & other nutrients such as vitamins & minerals are carried thru the bloodstream to your brain Enzymes convert amino acid precursors into neurotransmitters. Enzymes convert amino acid precursors into neurotransmitters.  Or the conversion takes place indirectly by causing insulin to be released from your pancreas which draws amino acids from your blood and tissues

24. Introduction to Cognitive Behavioural Therapy in the Treatment of Anxiety Disorders Dr Tim Dunne Consultant/Registered Clinical Psychologist Webster University, Geneva 5 th & 6 th November 2010 www.carlowpsychology.iewww.carlowpsychology.ie © www.carlowpsychology.ie

25. 6 th November Therapeutic Universals of Treatment Therapeutic Universals of Treatment Factors Determining Outcome in Therapy Factors Determining Outcome in Therapy Therapist/Patient Differences in Expectations Therapist/Patient Differences in Expectations Core Concepts of CBT Treatment approach Core Concepts of CBT Treatment approach Development of CBT Development of CBT Language & CBT Language & CBT Resource Building Case Formulation in CBT & Case Study CBT & Treatment of Anxiety, Panic Disorder & Phobias CBT Treatment of Life Stage. Existential & Health Anxieties Treatment of PTSD  Workshop Conclusion & Evaluation

26. Life Stage Development Anxieties Early Adulthood Who will I be 20’s /30’s ?? Mid-Life Who am I 35 - 50 yrs Later Adulthood Who was I? 65 yrs +

27. 3 Phases of Therapy RECOVERING DISCOVERING UNCOVERING

28. Therapeutic Universals Most therapists get good results consistently (Lambert & Baley, 2002) Most therapists get good results consistently (Lambert & Baley, 2002) Patients who drop out do so because they have met their goals (Pekarik, 1992) Patients who drop out do so because they have met their goals (Pekarik, 1992) Different schools of Therapy are about equally effective (Fonagy & Roth, 1996) Different schools of Therapy are about equally effective (Fonagy & Roth, 1996) Therapists are poor judges of their own successes/failures (Arden, 2010) Therapy can and does hurt people (Lambert & Ogles, 2004)  40% of patients would get better without therapy (Andrews & Harvey, 1981)

29. Therapeutic Universals Who the Patient is, is the most salient factor affecting outcome (Lambert, 2004) Who the Patient is, is the most salient factor affecting outcome (Lambert, 2004) Empathy, Warmth & Positive Regard are central to success of whatever school of Therapy (Fonagy & Roth, 1996) Empathy, Warmth & Positive Regard are central to success of whatever school of Therapy (Fonagy & Roth, 1996) Therapeutic Relationship (Alliance, Therapist’s empathy & consensus on goals) is crucial to success (Norcross, 2002) Therapeutic Relationship (Alliance, Therapist’s empathy & consensus on goals) is crucial to success (Norcross, 2002) Therapist’s credibility, skill, empathic understanding & affirmation of patients, capacity to engage with Pts, focus on their problems (Orlinsky et al, 1994) Successful repair of ruptures to the therapeutic alliance (Norcross, 2002)  Dual Process in Therapy – Learning and Unlearning going on at the same time

30. Factors Determining Outcome in Therapy (Lambert, 2006)

31. Therapist/Patient Differences (Arden, 2009, 2010) Therapists typically think that more sessions will be required than patients do Therapists typically think that more sessions will be required than patients do 70% of Pts said that they wanted 10 sessions or fewer 70% of Pts said that they wanted 10 sessions or fewer 50% of Pts expected 5 sessions or less 50% of Pts expected 5 sessions or less Most patients seek advice, problem definition, problem- solving and lots of therapist interactivity 70% of change occurs by the 7 th session  “Most patients want it short, sweet and effective” (Arden)

32. Historical Development of CBT Behaviourism (Pavlov, Watson & Skinner 1900 – 1930s) Behaviourism (Pavlov, Watson & Skinner 1900 – 1930s) Behaviour Therapy (Wolpe, 1950 – 1960s) Behaviour Therapy (Wolpe, 1950 – 1960s) Rational Emotive Therapy (Ellis 1970s) Rational Emotive Therapy (Ellis 1970s) Cognitive Therapy (Beck, 1980s) Cognitive Therapy (Beck, 1980s) MBCBTTFCBTDBT MBCBTTFCBTDBT

33. Core Concepts of CBT Cognitive – refers to all our conscious mental events or processes such attitudes, ideas impressions, images, beliefs, memories, perceptions, beliefs, assumptions, values, attention, reasons etc Cognitive – refers to all our conscious mental events or processes such attitudes, ideas impressions, images, beliefs, memories, perceptions, beliefs, assumptions, values, attention, reasons etc Behaviour – refers to what we do & what we avoid especially Safety Seeking behaviours Therapy – refers to a particular approach used to deal with a problem

34. Core Concepts of CBT Our thoughts influence our emotions which in turn influence behaviour – what we think affects what we feel and do. Our thoughts influence our emotions which in turn influence behaviour – what we think affects what we feel and do. It is not what happens to us in life that is important but how we chose to interpret it. It is not what happens to us in life that is important but how we chose to interpret it. “There is nothing either good or bad but thinking makes it so” – Hamlet, Shakespeare “There is nothing either good or bad but thinking makes it so” – Hamlet, Shakespeare  “Men are not disturbed by events, they are disturbed by the interpretation of which they make of them” – Epictetus (50 – 138 AD)

35. Core Concepts of CBT Psychoeducation / Information Psychoeducation / Information Mindfulness including Breathing Mindfulness including Breathing Cognitive Distortions Cognitive Distortions Exposure/Desensitization & Cognitive Restructuring Exposure/Desensitization & Cognitive Restructuring Relapse Prevention Relapse Prevention NATs – Negative Automatic Thoughts NATs – Negative Automatic Thoughts Compassionate Mind Compassionate Mind Cognitive Triad = Negative view of Self, Current Experience & the Future Antecedent – Trigger - Interpretation - Danger Behaviour – What is it exactly we do or don’t do/avoid Consequences – Feeling/Emotion Recordings of Thoughts/Feelings  Underlying Beliefs / Assumptions

36. Core Concepts of CBT Beliefs – I’m Odd/Weird/Weak/ Stupid/Boring/ Unattractive/Useless Beliefs – I’m Odd/Weird/Weak/ Stupid/Boring/ Unattractive/Useless There’s no hope for me There’s no hope for me What's the point? What's the point? I’m damaged goods I’m damaged goods It’ll always be like this It’ll always be like this It’s all my fault It’s all my fault I’m Unlovable I’m Unlovable I don’t deserve love etc I don’t deserve love etc Assumptions = Rules for living which develop early in life, possibly even before language/speech I have to make other people like me/ happy You must always obey the rules Others should know how I feel  Its my fault if the conversation lags

37. Core Concepts of CBT Focus on Thoughts, Feelings & Behaviours Focus on Thoughts, Feelings & Behaviours Defines Problems & Goals Defines Problems & Goals Formulation Formulation Uses evidence Uses evidence Collaborative Collaborative Structured Encourages Self-Help Homework Tests out new ideas & behaviours  Measures & Records

38. Core Concepts of CBT NATs Hierarchy - NATs Hierarchy - Responsibility / Blame Responsibility / Blame Safety / Danger Safety / Danger Choice / Control Choice / Control  Self-defectiveness

39. Basic Assumptions (Janoff-Bulman,1992) The World is Benevolent The World is Benevolent The World is Meaningful The World is Meaningful The Self is Worthy The Self is Worthy  Bad Things don’t happen to Good People

40. General Principles of CBT Thorough Behavioural Assessment before Treatment begins Thorough Behavioural Assessment before Treatment begins Main goal of CBT is to help Patients bring about desired changes in their lives Main goal of CBT is to help Patients bring about desired changes in their lives Treatment focuses on new learning and generalization outside the Therapy room Treatment focuses on new learning and generalization outside the Therapy room Problem-solving is an important element in CBT Problem-solving is an important element in CBT All aspects of Therapy are made explicit to Patient Collaborative effort between Patient & Therapist CBT is time-limited with explicit goals Emphasis on the Here & Now  Patient is helped to recognize patterns of distorted thinking & dysfunctional behaviour

41. Language & CBT Language is not neutral – Language is not neutral – Statements of Fact V. Statements of Value Certain kinds of words = emotional & judgemental Certain kinds of words = emotional & judgemental (eg) Mistake v. Error; Blame V Responsibility Absolute types of words such as “Always / Never” lead to certain types of feelings and leave us little room to manoeuvre, emotionally speaking Absolute types of words such as “Always / Never” lead to certain types of feelings and leave us little room to manoeuvre, emotionally speaking Catch all type words (eg) “Upset/Awful/Terrible” Catch all type words (eg) “Upset/Awful/Terrible” Taking Responsibility – encourage use of “I” rather than accept “You/One” Taking Responsibility – encourage use of “I” rather than accept “You/One” Alexithymia = “Emotional Illiteracy” – person does not have the words to express feelings / emotions – Feelings list Alexithymia = “Emotional Illiteracy” – person does not have the words to express feelings / emotions – Feelings list Socratic Questioning Socratic Questioning  Sensations V Feelings V Emotions

42. Resource Building Very important to develop Patient’s resources/coping skills for Affect Regulation Very important to develop Patient’s resources/coping skills for Affect Regulation Deep Breathing Deep Breathing Safe Place exercise Safe Place exercise Hand on Heart Hand on Heart SUDS – Subjective Units of Distress scale – 0 to 10 SUDS – Subjective Units of Distress scale – 0 to 10 Healing Light exercise for Pain Mgt Healing Light exercise for Pain Mgt Boundary Development Compassionate Mind Mindfulness/Present Focus Grounding Challenging your Thoughts Re-framing Normalizing the feeling/sensation  Validating their experiences

43. Formulation in CBT “Formulation provides an hypothesis about a patient’s difficulties which draws upon psychological theory” – Johnstone & Dallos (2006) “Formulation provides an hypothesis about a patient’s difficulties which draws upon psychological theory” – Johnstone & Dallos (2006) Its purpose is to relate all the patient’s complaints to one another and explain how the person developed these difficulties Its purpose is to relate all the patient’s complaints to one another and explain how the person developed these difficulties  It provides a plan of intervention based on psychological processes & principles

44. Formulation in CBT Draws on Cognitive & Behavioural theory Draws on Cognitive & Behavioural theory Collaborative Empiricism between Pt & Therapist Collaborative Empiricism between Pt & Therapist CBT Formulations are always provisional CBT Formulations are always provisional Formulation provides a framework for intervention Formulation provides a framework for intervention Good therapeutic relationship with Pt is necessary in CBT Focus on current problems and mutually agreed goals  CBT Formulation is not Diagnosis under another name

45. Formulation in CBT Presenting Issues – in terms of Emotions, Thoughts & Behaviours Presenting Issues – in terms of Emotions, Thoughts & Behaviours Precipitating Factors – Proximal External & Internal triggers for the PIs Precipitating Factors – Proximal External & Internal triggers for the PIs Perpetuating Factors – Internal & External factors that maintain the PIs Perpetuating Factors – Internal & External factors that maintain the PIs Predisposing Factors – Distal External & Internal factors that increased Pt’s vulnerability to current PIs Predisposing Factors – Distal External & Internal factors that increased Pt’s vulnerability to current PIs  Protective Factors – Pt’s Resilience & Strengths and Social Supports available

46. Case Study Read Case Study Read Case Study Use Case Formulation sheet Use Case Formulation sheet In Groups discuss your individual findings and any differences which may have arisen between you in terms of your Formulation and Why etc In Groups discuss your individual findings and any differences which may have arisen between you in terms of your Formulation and Why etc  How does this CBT approach compare with other therapeutic models?

47. CBT Treatment of Anxiety (GAD & Social), Panic & Phobias Agree Treatment Goals/Manage Pt’s Expectations Agree Treatment Goals/Manage Pt’s Expectations Case Formulation following detailed Behl Assessment Case Formulation following detailed Behl Assessment Resource Building – see earlier slide Resource Building – see earlier slide Deep Breathing Deep Breathing SUDs /Log Recording of Anxiety/Stress SUDs /Log Recording of Anxiety/Stress Safe Place exercise Safe Place exercise Boundary Development Boundary Development Mind your Language! Mind your Language! Thought Stopping Thought Stopping Ruminating V Reflecting Ruminating V Reflecting Normalize body sensations Psychoeducation on Anx/PAs – Hand-outs Information on Flight/Fight/Freeze Response Compassionate Mind/ Mindfulness Use Stories whenever possible & appropriate Identify NATs Identify Beliefs/Assumptions What's the worst that can happen? “Futurizing/Pasturizing” (Dunne)  “Musturbation” (Ellis)

48. CBT Treatment of Anxiety, Panic & Phobias Exposure to the feared stimulus – Encourage Disconfirming experiences & Self-Mastery Exposure to the feared stimulus – Encourage Disconfirming experiences & Self-Mastery Discourage Safety seeking behaviours in real life Discourage Safety seeking behaviours in real life Behavioural Experiments Behavioural Experiments Graduated Desensitization/Hierarchy of Feared Situations/Objects/Stimuli Graduated Desensitization/Hierarchy of Feared Situations/Objects/Stimuli Cognitive Re-Structuring/Interweave Cognitive Re-Structuring/Interweave Challenge Pt’s Thoughts/Beliefs/ Assumptions Challenge Pt’s Thoughts/Beliefs/ Assumptions “Court Room Drama” (Dunne) “Court Room Drama” (Dunne) Review each session with Pt Review each session with Pt Begin next session with Review of past week Begin next session with Review of past week  Relapse Prevention

49. CBT Treatment of Life Stage, Existential, Bereavement & Health Anxieties Resource Building Resource Building Supportive Therapy Supportive Therapy Normalize the Anxieties/PAs associated with each major Life Transition (eg) Becoming a fully functioning autonomous adult; Doubts & Identity Issues @ Midlife; Retirement & Old age Normalize the Anxieties/PAs associated with each major Life Transition (eg) Becoming a fully functioning autonomous adult; Doubts & Identity Issues @ Midlife; Retirement & Old age Build up a store of anecdotes & stories Judicious self-disclosure can be helpful Suggest Reading on key themes (eg) Victor Frankl’s “Man’s search for Meaning” Validate & Legitimize the Patient’s experiences  Present Focus in crisis

50. Treatment of PTSD Aim is not Cure but Affect Regulation Aim is not Cure but Affect Regulation Remember Relaxation Training and Non-Directive Therapy are contra-indicated for treating PTSD (NICE, 2005) Remember Relaxation Training and Non-Directive Therapy are contra-indicated for treating PTSD (NICE, 2005) Effective Treatment of PTSD is not about Re-living the experience but helping the Pt let go of the strong affect and experience safety in the present Effective Treatment of PTSD is not about Re-living the experience but helping the Pt let go of the strong affect and experience safety in the present Mindfulness by both Therapist and Pt are important in the process Mindfulness by both Therapist and Pt are important in the process “That was then, this is now” approach “That was then, this is now” approach Bottom up approach rather than traditional Top down Bottom up approach rather than traditional Top down  Resource Building before any treatment begins

51. Treatment of PTSD: Fisher (2008) In traditional talking treatments, we tend to treat thoughts, feelings, and body sensations as if they were one and the same phenomenon: In traditional talking treatments, we tend to treat thoughts, feelings, and body sensations as if they were one and the same phenomenon: For example, when we say, “I feel unsafe,” It could reflect a cognition: “I am never safe,” “The world is not a safe place” It could reflect a cognition: “I am never safe,” “The world is not a safe place” It could mean an emotion: “I’m feeling frightened” It could mean an emotion: “I’m feeling frightened”  It could mean a bodily sensation: “My chest is tight; my heart is racing; it’s hard to take a breath”

52. Mindfulness in PTSD Mindfulness in therapy depends upon the therapist becoming more mindful: slowing the pace of thinking and talking, refraining from interpretation in favor of observation, helping the patient begin to focus on the flow of thoughts, feelings, and body sensations as these unfold Mindfulness in therapy depends upon the therapist becoming more mindful: slowing the pace of thinking and talking, refraining from interpretation in favor of observation, helping the patient begin to focus on the flow of thoughts, feelings, and body sensations as these unfold Because mindful attention is present moment attention, we use “retrospective mindfulness” to bring the client into present time: “As you are talking about what happened then, what do you notice happening inside you now?” Because mindful attention is present moment attention, we use “retrospective mindfulness” to bring the client into present time: “As you are talking about what happened then, what do you notice happening inside you now?”  Curiosity is cultivated because of its role as an entrée into mindfulness: “So, when you talk about your father, your heart beats faster and you feel afraid... “

53. Treatment of PTSD Present Focus with emphasis on Safety in the Here & Now Present Focus with emphasis on Safety in the Here & Now Normalizing the body’s responses and somatic experiences associated with the Trauma event Normalizing the body’s responses and somatic experiences associated with the Trauma event Identify Negative Cognitions arising from the Trauma - “What does that say about you as a person?” Identify Negative Cognitions arising from the Trauma - “What does that say about you as a person?” Identify which level of NC this is Identify which level of NC this is  Use Cognitive Interweave as and when appropriate

54. Treatment of PTSD Develop sense of Self-Efficacy for the Pt Develop sense of Self-Efficacy for the Pt “Hindsight Bias” “Hindsight Bias” Binocular Effect Binocular Effect Identify the Body’s “Old Stuff” reactions and place it historically Identify the Body’s “Old Stuff” reactions and place it historically Encourage Pt to continue to breathe at all times Encourage Pt to continue to breathe at all times Ground, de-brief and orient the Pt at end of Therapy session Ground, de-brief and orient the Pt at end of Therapy session  Relapse Prevention

55. Conclusions Review Chart Expectations with group Review Chart Expectations with group Summarize workshop overall themes Summarize workshop overall themes  Evaluation sheets