The role of cognitive behaviour therapy in developing patients’ self –management skills.

1. School of Nursing 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

2. 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 self-management skills

3. Living well: Basic principles • Hope • Self-responsibility • Self-advocacy • Education • Meaning – purpose – direction • Support

4. 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).

5. 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).

6. How do representations of illness shape health responses and behaviours?

7. Protective factors • The things in our lives that keep us mentally well and build resilience: • 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

8. 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 stressand more able to adopt health-promoting behaviors and attitudes.

9. 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 salutogenicorientation (Antonovsky, 1979)

10. 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)

11. A strong SOC enables the individual to comprehend stressful situations And Interpret them as manageable and see them as meaningful in terms of facing the challenge these situations pose

12. 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.

13. Self direction: Concerned with self-motivation and taking initiative to employ problem-solving strategies when faced with stressful situations Self efficacy: Relates to the belief in one’s ability to cope effectively when faced with adversity.

14. 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

15. 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

16. The active involvement of the client • Socratic questioning includes • 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

17. 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

18. 5 PART MODEL (Padesky & Mooney, 1990) Person’s environment situation beliefs thoughts moods biology context spiritual history culture behavior

19. THE BASIS OF THE CBT MODEL • “It is not the events themselves that disturb us, it is our interpretation of those events” • (Epictetus)

20. Three levels of thinking • Automatic thoughts • Underlying assumption or rules for living • Core beliefs (schema)

21. 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”

22. 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

23. 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”

24. 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”

25. 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

26. Activity makes people feel betterActivity makes people feel less tiredActivity motivates people to do moreActivity improves thinking abilitySignificant others respond differentlyHelping people to become active again if they have been inactive for long periods takes time

27. Becoming Active Again • TARGETS:LOWERED MOTIVATIONDECREASED ACTIVITYANHEDONIA

28. 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

29. 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).

30. 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

31. Self-efficacy Using guided discovery to cognitively restructure beliefs, therefore developing more alternative and balanced beliefs about self, world/others and future.