From Symptom to Solution:
a brief, 3 step protocol for CBT
Paul Rijnders
Clinical 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,
• SPD :
8 sub-steps
- 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:
M.3
- Termination and Relapse Prevention
(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 patiënte
Geboortedatum: 1978
Geslacht:
Vrouw
Behandellocatie: Oosterschelderegio
Behandelfase:
nog geen of 1 gesprek gehad
Testdatum:
23-02-2010
-----------------------------------OQ45-score: 75.
Sub-schales
Symptom Distress:
Interpersonal relations:
Sociale Rol:
Critical Items
Suicide:
Substance abuse:
Violaence:
51 This score is high
10 This score is normal
14 This score is above average
Yes
No
Yes
Er is een hoge factorlading op
Depression/anxiety:
Yes
Feeling of Well-being:
Yes
Impact of Stress:
Yes
“the psychological thermometer”
•
Gegevens van patiënte
Geboortedatum: 1978
Geslacht:
Vrouw
Behandellocatie: Oosterschelderegio
Behandelfase:
nog geen of 1 gesprek gehad
Testdatum:
23-02-2010
180
-----------------------------------OQ45-score: 75. .
Sub-schales
Symptom distress:
Interpersonal relations:
Social Roles:
Critical Items
Suicide:
Substance abuse:
Violence:
51: H
10 : N
14 :above A
yes
No
Yes
Er is een hoge factorlading op
Depression/anxiety:
Yes
Feeling of Well-being:
Yes
Impact of Stress:
Yes
87
55
0
Your psychological temperature
•
Gegevens van patiënte
Geboortedatum: 1978
Geslacht:
Vrouw
Behandellocatie: Oosterschelderegio
Behandelfase:
nog geen of 1 gesprek gehad
Testdatum:
23-02-2010
180
-----------------------------------OQ45-score: 75. Deze score is hoog.
87
Sub-schalen
Symptom distress:
Interpersonal relations:
Social Roles:
Critical Items
Suicide:
Substnce abuse:
Violence:
51 H.
10 N.
14 above A
Yes
No
Yes
Er is een hoge factorlading op
Depression/anxiety:
Yes
Feeling of Well-being:
Yes
Impact of Stress:
Yes
75
55
0
Step I, Sub-step 1:
Restoring overview
• Dialogue
• Patient’s report
• Measurement
Manageable bits
Sd – Ci - Cs - outline
description
Symptom distress (Sd)
Circumstances (Ci)
.
Coping style (Cs)
“habits”
l
Sd – Ci - Cs - outline
description
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
l
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
NS
Below
average
Normal
X
X
P
SD
X
X
C
ST
High
X
HA
RD
Above
average
X
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 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”
•
From Florance N. to:
•
From: “absolute single”
•
From: throwing in the towel to: deliberated action
•
From: bull in China shop to:
to: “yes, but”
“in between”
to:
“ a little cooperation”
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:
• Quality of life:
• Satisfaction:
No difference
No difference
No difference
• Needed amount of sessions: BT:
• % Relapse: not available yet
30% less.
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)
OQ-45.2-Total Means
OQ_Total_group
100,00
low
mild
high
very high
80,00
60,00
40,00
1
2
time
3
Conclusion
• Guided/shared exploration and planning +
• Guided SL, BE and CR +
• Low threshold
• (at least) same result but in shorter time