From Symptom to Solution: a brief, 3 step protocol for CBT

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? 7 - 8 % • Which percentage of this group receives professional mental health treatment? between 25% and 55% (differs per country)

5. Question What works in CBT ?

6. 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)

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:

11. Questionaires: (OQ-45) • Gegevens van patiënteGeboortedatum: 1978 Geslacht: VrouwBehandellocatie: OosterschelderegioBehandelfase: nog geen of 1 gesprek gehadTestdatum: 23-02-2010------------------------------------OQ45-score: 75. Sub-schalesSymptom Distress: 51 This score is highInterpersonal relations: 10 This score is normal Sociale Rol: 14 This score is above averageCritical ItemsSuicide: Yes Substance abuse: No Violaence: YesEr is een hoge factorlading opDepression/anxiety: YesFeeling of Well-being: YesImpact of Stress: Yes

12. “the psychological thermometer” 180 • Gegevens van patiënteGeboortedatum: 1978 Geslacht: VrouwBehandellocatie: OosterschelderegioBehandelfase: nog geen of 1 gesprek gehadTestdatum: 23-02-2010------------------------------------OQ45-score: 75. .Sub-schalesSymptom distress: 51: H Interpersonal relations: 10 : N Social Roles: 14 :above ACritical ItemsSuicide: yes Substance abuse: No Violence: Yes Er is een hoge factorlading opDepression/anxiety: YesFeeling of Well-being: YesImpact of Stress: Yes 87 55 0

13. Your psychological temperature 180 • Gegevens van patiënteGeboortedatum: 1978 Geslacht: VrouwBehandellocatie: OosterschelderegioBehandelfase: nog geen of 1 gesprek gehadTestdatum: 23-02-2010------------------------------------OQ45-score: 75. Deze score is hoog.Sub-schalenSymptom distress: 51 H. Interpersonal relations: 10 N. Social Roles: 14 above ACritical ItemsSuicide: Yes Substnce abuse: No Violence: YesEr is een hoge factorlading opDepression/anxiety: YesFeeling of Well-being: YesImpact of Stress: Yes 87 75 55 0

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

15. Sd – Ci - Cs - outline

16. Sd – Ci - Cs - outline

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

18. Step I, Sub-step 2example 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

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

22. Step II: Behaviour Change

23. Step II: Behaviour Change • 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 imitationThe 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 andCognitions / 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 7gedachten uitdagen

37. measurement 2:Evaluate and what next

38. Step III, sub step 8Termination 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 2Van 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 3Heene et al,

43. Heene et al 2011

44. Severity at start

45. OQ-45.2-Total Means OQ_Total_group 100,00 low mild high very high 80,00 60,00 40,00 1 2 3 time

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