CBT skills

CBT skills

CBT top tips for clinicians!

I'd love to pass on reviews of workshops, books, research, and focus on the material that's clinically useful. It would be great if you could take away a new idea or technique that you could use straight away with your patients.

Nottingham OCD conference 2014

This might help your patients.Posted by Philip Kinsella Wed, December 10, 2014 15:14:46

This conference was great in that clinicians and sufferers attended together. The patients I heard to were inspiring: I took away a message about always being upbeat about treatment.

Main Clinical take aways:

It's reasonable to help the patient understand that no OCD patient has acted on his or her worries.

Be upbeat about our treatments: they do work

Work together, agreeing a wide variety of specific exposure type experiments, ensuring that the person does anti-OCD, previously called overlearning

Be aware of the risks to the patient of their OCD.

Always screen for BDD.

Engage the patient with OCD-UK.

Here's a summary of individual talks:

Patient experience of treatment. Lomax and Forrester.

What patients would like the therapist to know.

1 Learn as much as you can about OCD.

2 Honestly build trust and collaboration. be honest your level of experience.

3 Know what you might find difficult in treating the patient. Understand the real risks, of the effect of OCD on their lifestyle. Seek advice from religious leaders if you're not sure about religious beliefs. Remember that no OCD patient has carried out his or her obsession.

4 Work together. Be collaborative not argumentative. That relationship the patient has with you is really important. You are both experts. Normalise.

5 Consider what you can achieve in the time you have available. Be creative in designing sessions. Consider practicalities.

6 Some homework rules: homework is not the best term. Try to make it interactive. Make it clear and easy to follow. Best Homework rules: clear rationale, set together, no lose experiments and always review, get patient to be more active in setting homework as therapy goes on. What makes homework difficult is: practicalities can be too hard as set by therapist, patient's negative predictions, perfectionism about homework. Break it down into steps. Ask 'What did you learn from doing the homework'

7 Get out of your chair and do stuff!

8 When setting up homework: work on specific belief. Identify safety behaviours. Identify what would get in the way of good data collection.

9 Do active experiments: testing beliefs and learning about maintenance factors.

10 Address the issue of reassurance. Patients can be sneaky.

11 Get a co therapist. Tape record session for patient. Use worksheets. Use Internet resources and OCD-UK.

12 OCD-UK forum is a fantastic resource.

13 Be realistic but stay hopeful. Important to eradicate all OCD beliefs.

14 Recovery is a marathon not a sprint.

15 I found this very useful!

Professor Mark Freeston 'Risk in OCD'

Mark re-iterated that probability of acting on obsession is non-existent.

If the therapist is unsure whether it is OCD or the person really is dangerous here are some guidelines:

More like OCD: Ego systonic. Unwanted. Fear it is ego systonic. Fear that if they act on. It they won't be the person they want to be. Will avoid triggers. Fear of disclosure. Extreme measures to prevent harm.

Less like OCD: Egosyntonic. Often wanted. Becomes part of fantasies. May seek out triggers and want to act on it. Fear is of punishment.

How to approach people if you suspect it's OCD. 'I don't need to know details but can you give me the area' 'Am I getting nearer to guessing what your thoughts are?'

Don't be shocked as a therapist!

Be empathic and curious. Normalise. Suspend judgment until all information is available.

Give legitimate information but not reassurance. If patients repeatedly ask the same question it may be reassurance. Say 'let's see if we can make sense of this'

There is no simple question that can determine whether the person has OCD.

Patients can misinterpret signs of anxiety as sexual arousal.

They may believe 'if I have this thought I will do it/I want to do it/the thought is equivalent to doing it'. This is TAF.

Don't quickly challenge thoughts, but be curious.

There is a real potential for harm to OCD patients from hasty risk assessments. Take time to be confident it is OCD. Act as an advocate for the patient.

Comorbitites that increase risk: depression. Psychosis antisocial PD.

Secondary risk to patient from their OCD is a big concern: suicide. Not eating. Stop cleaning themselves. Neglect of others because of OCD (rare). Can occasionally be angry because they are stopped doing rituals.

David Veale Body dysmorphic disorder.

There's a low level of awareness of the condition

Presentation to dermatologists is common. Patients are secretive. Little research.

Onset adolescence. 10-15 years to treatment. Equal sex.

Diagnosis: In DSM 5. (it has been categorised with OCD.)

Preoccupation with flaws not observable to others. Repetitive behaviours. E.g. checking mirror gazing, Picking, facial exercises are common. 0.3% p.a. suicide.

Causes distress e.g. Depression, anxiety, and shame.

Some are more externally focused on what others think but others more internally focused others more OCD.

Always screen for this. 'Are you over bothered about the way you look?' Get people to do self-portrait.

CBT model of maintenance: Extreme self-consciousness. Attentional bias. Aesthetic rules for themselves. Comparisons with others.

Risk factors: artistic background. Bullying. Poor attachments.

BDD: Key concern about being different related to bullying experience at school. These memories may not have been emotionally processed. Self as an aesthetic object linked to self focused attention.

Need to follow NICE guidelines. There are four small trials.

Patients less likely to do well if depressed or in secondary care. Less than 28% were cured, most had subclinical symptoms. 15% had no improvement. 56% some improvement. Difficult to treat.

Treatments: Focus on process not content. Imagery rescripting. Exposure.

Medication can help. Fluoxetine is modestly helpful. No evidence for antipsychotic drugs.

Advise on cosmetic procedures. Likely to be dissatisfied.

Engaging patients say 'you're very sensitive about your appearance'. Theory a and theory b.

Reassurance seeking in OCD.

Halldorson Salkovskis Russell.

Normal reassurance is helpful. We use it all the time in childhood.

In emotional problems it stops being helpful. Takes various forms. Functions as a safety seeking behaviour. Can be subtle.

Self reassurance more like mental checking.

Current literature has problems. Is a complicated concept. Is all over the place. Not just associated with health anxiety. Functions differently in different disorders.

It's a complex interpersonal behaviour: patient asking. The person provides. The patient does something with the reassurance.

Clinical wisdom. Usually viewed in medical circles as a good thing.

In CBT viewed as a bad thing.

Looking at reassurance from different angle. Caregivers feel stuck. Resisting this causes interpersonal problems. It makes sense to give it. 'What else can we do?'

People with OCD seek reassurance:

To deal with threat and avoid responsibility. Giving reassurance is helpful in the immediate term.

Therapists understand reassurance is common. Therapist may be using 'stop giving reassurance' unhelpfully.

Therapists should help patients transform reassurance seeking into positive alternative. E.g. help seeking. Getting help to cope with problem.

Anti OCD is the key. Dr Elizabeth Forrester.

Not treating the whole wound is like having a bit of infection

Aim of therapy is to do things the way most people do things.

Anti OCD is chasing the bully away. And increasing our comfort zone.

Anti OCD is to put bread knife on bedside table. Put joke poo on bed. Switch lights on and go out. Put bank statements in recycling without tearing them up. Play 'glad to be gay' on mp3. Make the anti- OCD part of everyday life.

Myth of the hierarchy. Paper by Abramovitz and Arch.

Basis of therapy is testing out more Positive beliefs.

Important Abramovitz paper on exposure

1 Use of ERP is not about habituation.

2 Learn that you don't need to fix anxiety.

3 Random tasks from hierarchy more effective

4 Patient needs to learn that they can tolerate anxiety and uncertainty.

5 Everyday opportunities maximise variability.

6 Learn to confront obsessional cues.

Why don't therapist do more anti OCD?

Put risk into perspective. Elimination of risk is impossible. What is acceptable risk?

Therapist issues

Be prepared to do it yourself.

Importance of modeling.

Does you supervisor understand

Therapist need to practice.

Summary

Doing extreme things gives us choice

Randomly allocate homework tasks

Don't push habituation model.

Tackle OCD as part of everyday life.

Take a lighthearted approach to tackling OCD.

Perinatal OCD. Dr Fiona Challecombe.

Perinatal illness costs society 1.8bn. Rate of 20%.

More common in first time mothers. Miscarriage. Pre existing appraisals of thoughts. Some people with OCD better in pregnancy.

Postnatal depression is often missed.

OCD under diagnosed. Patients don't seek help.

Anti obsessional tasks. Paul Slakovskis.

Help patient consider less threatening views of the situation.

Ask how does the world work the internal and external world.

Doing the checking is worse than not checking.

'You've got to do the things that you want patients to do!'.

Treatment resistant OCD is something of a myth



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How to get the best of ACT into your CBT practice.

This might help your patients.Posted by Philip Kinsella Wed, December 10, 2014 13:53:59

Review of ‘A CBT practitioner’s guide to ACT’ by JV Giarrochi and A Bailey.

Book description and review: This book describes the usual ACT philosophy and approaches, such as defusing from thoughts, observing the self, being in the now, accepting thoughts and feelings, and acting flexibly in pursuit of values. It looks at how CBT differs from ACT, and acknowledges (correctly) that it may be acceptable to challenge thoughts, as opposed to defusing from them, depending on the context. The authors say that if a patient values being accurate then challenging may be best, but if a patient believes something to obtain help, or make sense of the world, or blame someone else, then less so. It encourages the CBT practitioner to be less verbal, and be open to creating a slowed down mindful space in the therapy hour, sitting with distress. There is an excellent section on values, and I have always found that helping patients identify and engage with what their philosophy in life is (be kind…be intelligent…) works well, especially with depression and chronic pain.

There are fantastic exercises in this book including ‘milk’, and ‘monsters on the bus’ that can be incorporated into therapy.

This is an excellent book more philosophically aligned to the ACT approach, but striving to be fair to both. It’s written more clearly than some ACT books, with even ‘relational frame’ theory made fairly understandable. Having used both therapy approaches, I find them fairly equally effective, but I personally find CBT more acceptable: it is more collaborative and, I think more sophisticated from a theoretical point of view. The ACT approach is more genuinely side by side, ‘we’re all in it together’, and aims to bring about a more philosophical change in the individual, as opposed to just reducing a dysfunctional emotion.

Clinical application: If you use a Beckian approach try using the ACT defusion exercises like milk and monsters on the bus. The first is done by getting the person to say milk and see what it brings up, then to repeatedly say it, which can lead to defusing from meanings of milk. One can then try this with the person’s beliefs e.g. I’m stupid’, saying it repeatedly, quietly, loudly, like Mickey Mouse, like an opera singer. This is a powerful and humorous exercise but crucially the person has to be reassured that he is not being laughed at.

The monsters exercise has the patient driving the bus to the destination despite the passengers (therapist) trying to distract them by mouthing the drivers negative thoughts. This is a fun exercise, which works well. The patient can be invited to see the various effects of ignoring, arguing with or accepting of the passengers’ comments.

Values work can be done by getting the patient to fill in the values questionnaire, and to rate their adherence to their values. Imaging your eulogy is a more emotionally powerful version of this. This strategy can enhance the Beckian mastery and pleasure approach by targeting the range of activities more thoughtfully.



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