The role of cognitive behaviour therapy in
developing patients’ self –management skills.
Dr Helen P Hamer RN, PhD, FNZCMHN
Senior Lecturer/Nurse Consultant
School of Nursing & Centre for Mental Health Research
University of Auckland
h.hamer@auckland.ac.nz
School of Nursing
• An overview of the CBT model
• The principles of engaging a person in their
own change processes
• Example of a brief intervention
• Increasing resourcefulness and selfmanagement skills
Living well: Basic principles
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Hope
Self-responsibility
Self-advocacy
Education
Meaning – purpose – direction
Support
Paternalism V Autonomy
• Compliance:
• The extent to which a person's behaviour (in
terms of taking medications, following diets,
or executing lifestyle changes) coincides with
medical or health advice (Haynes, 1979).
Concordance
• Concordance (Moffatt, 2004) defines the
process of successful planning and delivery of
health care based on partnership.
• It has three essential elements:
• Patient has knowledge to participate as a
partner;
• Consultations involve patients as partners;
• Patients are supported during their treatment
(adapted from Medicines Partnership: www.medicines-partnership.org).
• How do representations of illness shape
health responses and behaviours?
Protective factors
• The things in our lives that keep us mentally well and build
resilience:
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Being able to problem solve and make decisions effectively
Social connections and sociability with others
Holding a positive self esteem or self regard
Having supportive partner/loved ones/ friends
Having positive role models
Being able to regulate strong emotion
Optimal physical health
Spiritual/cultural beliefs
Learned Resourcefulness (LR) (Rosenbaum 1990)
• Beliefs (whether he/she can effectively cope with
the situation)
• Self-control skills-highly resourceful people who
score high on ‘hardiness’ and have a strong sense
of coherence, are physically and psychologically
healthier
• Behaviors (adopting new health behaviors).
• LR leads to coping better with stress and more
able to adopt health-promoting behaviors and
attitudes.
LR and Learned Helplessness (LH)
• Helplessness refers to a psychological state
(Rachman, 1990)
• Resourcefulness refers to an enduring general
attribute
• Whereas helplessness originated from a
pathogenic model, resourcefulness has roots
in a salutogenic orientation (Antonovsky,
1979)
A Sense of Coherence
• A global orientation that expresses the extent
to which one has pervasive, enduring though
dynamic feelings of confidence
• That one’s internal and external environments
are predictable
• That there is a high probability that things will
work out as well as one can reasonably be
expected (Antonovsky, 1979)
• A strong SOC enables the individual to
comprehend stressful situations
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• Interpret them as manageable and see them
as meaningful in terms of facing the challenge
these situations pose
Defining Attributes of LR
(Zauszniewski, 1995)
• Self-control: which involves monitoring of
internal events, including thoughts, feelings
and sensations, for the purpose of preventing
interference with functioning or performance
of tasks.
• Self direction: Concerned with self-motivation
and taking initiative to employ problemsolving strategies when faced with stressful
situations
• Self efficacy: Relates to the belief in one’s
ability to cope effectively when faced with
adversity.
What is CBT?
• A problem-focused and goal orientated
psychotherapy based on the ‘here and now’
• CBT focuses on behavioural activation and the
monitoring of unhelpful (or erroneous) thoughts and
beliefs about the self, the world/others and the
future
• Has a substantial evidence-base for its usefulness in a
range of mental & physical health presentations
The guiding principles of CBT
• Centrality of the conceptualisation
• The collaborative relationship and the use of
empiricism
• Explicitness of the therapist
• The phenomenological emphasis
• The active involvement of the client (feedback,
homework etc.)
• The ‘outward’ focus
• The use of Socratic dialogue
The active involvement of the client
• Socratic questioning includes
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asking questions that gain information about their world
empathic listening
frequent summarising
asking the person to synthesise and analyse the new
information about their current problem
• The Socratic style of questioning helps the
person the “think through their problems”
with the aim of helping the person to come to
their own conclusions and solutions
5 PART MODEL
(Padesky & Mooney, 1990)
Person’s environment
situation
thoughts
moods
context
beliefs
biology
history
behavior
culture
spiritual
THE BASIS OF THE CBT MODEL
• “It is not the events themselves that
disturb us, it is our interpretation of
those events”
• (Epictetus)
Three levels of thinking
• Automatic thoughts
• Underlying assumption or rules for living
• Core beliefs (schema)
Three levels of thinking
• Through faulty information processing:
• Automatic thoughts “I can’t control my diabetes, it is
too hard”
• Underlying assumptions are “If I don’t work hard
then I am a failure”
• Schemata or core beliefs “I’m inadequate” or “I’m a
failure”
Underlying assumptions
• ....Are the source of the thinking mistakes, and are of
varying strengths
• Social learning: e.g. always saying ‘please and thank
you’
• Religious learning: e.g. “shalt and shalt nots”
• Legal codes: from not killing or stealing to crossing at
the red/green light
• The individual's degree of belief in these
assumptions or rules will determine the strength that
the beliefs have as a well-spring of cognitive
distortions
Examples of underlying assumptions
• “If I let people know what I really think, then
they won’t like me”
• “If I say no to others then they will reject me”
• “If I avoid problems, then they will go away”
UA example
• A young child comes home from school after
receiving a 98% pass in the test, the parents overtly
or covertly inquire about the other 2%
• “I thought you knew the work?”
• “What happened to the other 2 points?”
• When he comes home with a perfect score next time
and is greeted with hugs and kisses, a basic rule for
this child could be:
• “To be accepted/loved/thought well of/ prized, then
I must always/should/ought to be perfect”
Visual Analogue Scale (VAS)
• INTRODUCING THE VAS
• Discuss the rationale for this tool
• Ask client to choose the most problematic mood that they
are experiencing
• Set specific anchors for this mood
• When anchoring the mood rating it is also important to
write down a brief summary of the information you elicit
from the client that describes the situation
• Practice recording their ratings at set times throughout the
day/week
• Activity makes people feel better
Activity makes people feel less tired
Activity motivates people to do more
Activity improves thinking ability
Significant others respond differently
Helping people to become active again if they
have been inactive for long periods takes time
Becoming Active Again
• TARGETS:
LOWERED MOTIVATION
DECREASED ACTIVITY
ANHEDONIA
QUESTIONS FOR CLIENT AND THERAPIST
TO GUIDE DISCOVERY
Did my activities affect my mood?
What activities made me feel better?
What activities made me feel worse?
Were there certain times of the day I felt worse?
Can I think of anything I could do that would help, when I feel this way?
Note, which activities are under and over-represented (aim for balance)
Propose one, or some, changes that the client is willing to try out
The Skills to Learn and Master for
Learned Resourcefulness
• Self-control: the use of daily activity schedules
to monitor behavior and interaction socially
• Incorporation of the negative automatic
thought record to identify themes in thinking
• Identifying cognitive errors, including
attribution, assumptions, rules and beliefs
(the negative cognitive triad).
Self-direction
• Develop problem-solving skills and
communication styles that maintain healthy
relationships in their social arena e.g.
• Assertion skills
• Social skills training with role-play practice in
session
Self-efficacy
• Using guided discovery to cognitively
restructure beliefs, therefore developing more
alternative and balanced beliefs about self,
world/others and future.