� Dr. Kanwal D. S. Kukreja MBBS, DCH, FRCP(C)

Assistant Clinical Professor, Psychiatry and Behavioral Neurosciences, Mcmaster University

Attending Psychiatrist, Grand River Hospital – Freeport site, Kitchener

A Day in Psychiatry- 2017

Wednesday November 8th, 2017

Bingeman’s Conference Centre

Kitchener, Ontario

Declaration of Conflict of Interest:

I HAVE received honoraria for attending advisory board meetings on behalf of Otsuka and Lundbeck pharmaceutical companies.

I DO NOT INTEND to make therapeutic recommendations for medications that have not received regulatory approval

(e.g “off-label”use).

THIS 2017 DAY IN PSYCHIATRY DAY IN PSYCHIATRY DAY IN PSYCHIATRY DAY IN PSYCHIATRY EDUCATIONAL EVENT HAS RECEIVED

UNRESTRICTED EDUCATIONAL GRANTS FROM THE FOLLOWING

ORGANIZATIONS:

�Lundbeck

�Otsuka

�Pfizer

�Janssen

�Purdue

�Shire

�Sunovion

�KW Guardian Pharmacy

�HLS Therapeutics

�Allergan

Mitigating Potential Conflicts of Interest:

Since this presentation does not deal with pharmacological treatment, there is no potential for conflict of interest.

1. Best practices in forming clinician-patient therapeutic alliances.

2. Reviewing factors which promote or inhibit the development of the therapeutic alliance.

3. Understanding how the therapeutic alliance underlies psychotherapeutic effectiveness.

4. Cognitive behavioural therapy

1. Discuss Cognitive Behavioural Therapy as a technique.

2. Evidence supporting the clinical effectiveness of CBT.

3. Review the process of CBT.

4. Practical suggestions to use in short patient interactions.

5. Local Resources for further study.

Alliance

Empathy

Expectations

Cultural adaptation

Therapist differences

� How important are common factors in psychotherapy

� Bruce WampoldWorld Psychiatry. 2015 Oct; 14(3)

� The therapeutic relationship ; The revival of hope ;Confronting problems; Developing a sense of mastery and competence ; Attributing success to one’s own efforts

� MOST THERAPEUTIC MODALITIES INCORPORATED ONE OR TWO OF THEM AND COMMON NEGLECT OF POTENT THERAPEUTIC VARIABLES

Weinberger 1995

� Repeated finding of no difference between therapies is the result of all methods doing equally BADLY , instead of notion that all are doing WELL Ecker 2016

� Almost all humanistic and supportive therapies focus on “therapeutic relationship” as the curative factor, even though research suggests it is responsible for 11% of the variance Horvath et al 2011; Martin et al 2000

� 40% of the variance was attributed to interventions designed to help patients confront what they have been avoiding

� Very little resource used to specific methods for helping patients confront the conflicts and difficulties they tend to avoid Weinberger 1995

� Reliance on data from RCT contributes to myth of common factors and Averaging data, all the significant variation between treatments is lost

Moderate use of specific factors, along with the common factors of empathy, safety, and curiosity, seem to yield the best results McCarthy, et al 2015; Wampold, 2015

Therapists who integrate specific dynamic interventions with more “common” experiential interventions tend to achieve the best outcome Barber, Muran 2013

Therapist is the most –potent but neglected variable. - Top 20%

Patient Factors

NUMBER AND SEVERITY OF SYMPTOMS

ABILITY TO RELATE TO PEOPLE

MOTIVATED TO IMPROVE

CAN IDENTIFY CENTRAL PROBLEM

� WARMTH, CONCERN AND GENUINENESS

� MUTUAL TRUST AND RESPECT

� DEVELOPING RAPPORT

� SHOWING COMPASSION

� ADHERING TO ETHICAL STANDARDS, SUCH AS PRIVACY, CONFIDENTIALITYAND HONESTY

� GIVING INFORMATION ABOUT YOUR ROLE AND ITS LIMITATIONS

� ABILITY TO ADAPT PERSONAL STYLE SO THAT IT ‘MESHES’ WITH THAT OF THE PATIENT

� AVOIDING UNHELPFUL INTERPERSONAL BEHAVIOURS (E.G. IMPATIENCE ORINSINCERITY).

� COLLABORATIVE ATMOSPHERE

� MUTUAL AGREEMENT

� TRUST

� ACCEPTANCE

� OPENNESS

� EMPATHY

� WARMTH

� Some basic level of TRUST surely marks all varieties of therapeutic relationships, but when attention is directed toward the more protected recesses of inner experience, deeper bonds of trust and attachment are required and developed

GREENBERG, ART AND SCIENCE OF BRIEF PSYCHOTHERAPIES

� Perceived loneliness is a significant risk factor for mortality, equal to or exceeding smoking, obesity, not exercising (for those with chronic cardiac disease or for healthy individuals), environmental pollution, or excessive drinking

� Psychotherapy provides the patient a human connection with an empathic and caring individual, which should be health promoting, especially for patients who have impoverished or chaotic social relations

Holt-Lunstad J, Smith TB, Baker M, et al. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci. 2015

� ABILITY TO MEET CLIENT EXPECTANCIES

� EARLY ALLIANCE PREDICTS OUTCOMES ACROSS DIFFERING APPROACHES INCLUDING PHARMACOTHERAPY

� NOT JUST CORRELATION BUT PREDICTION

� CLIENTS ARE GOING TO BE COMMITTED AND MOTIVATED

� ALLIANCE INTERACTS WITH OTHER FACTORS INCLUDING CLIENT CHARACTERISTICS

� FELLOW JOURNEYMAN

� UNDERSTAND WHERE PERSON IS ON THE CIRCLE OF CHANGE

� EMPATHIC UNDERSTANDING

PAY ATTENTION TO NOT ONLY CONTENT OF VERBAL REPORTS BUT ALSO

� CHANGES IN PATIENTS VOCAL QUALITY

� FACIAL EXPRESSION

� FOCUS

� EMOTIONAL INVOLVEMENT

� THERAPIST SUBJECTIVE FEELING

� BEGINNER’S MIND: OPEN TO EVERYTHING

� BE PREPARED FOR AMBIGUITY, UNCERTAINTY, AND SOMETIMES PAIN

� THIS IS A TWO PERSON PSYCHOLOGY – THE PATIENT –THERAPIST RELATIONSHIP IS THE OBJECT OF STUDY – A COPARTICIPANT

� OBSERVING - PARTICIPATION

� INTERVENTIONS AS RELATIONAL ACTS – COMMUNICATION HAS A REPORT ASPECT WHICH IS THE CONTENT AND A COMMAND ASPECT WHICH IS THE IMPLICIT INTERPERSONAL STATEMENT BEING CONVEYED

� MOTIVATION AND EMOTION

� AFFECTIVE COMMUNICATION (DIALOGUES) OF THE UNCONCSCIOUS AND THE CONSCIOUS

� EMOTIONS AROUSED IN THE THERAPIST ARE MUCH NEARER TO THE HEART OF THE MATTER THAN REASONING

� EMOTIONS PROVIDE US WITH RAPID AND ECONOMICAL APPRAISAL OF WHAT EVENTS AND INTERPERSONAL INTERACTIONS MEAN TO US AS BIOLOGICAL BEINGS

� THERAPISTS ABILITY TO ATTUNE TO THEIR PATIENTS’ UNARTICULATED EMOTIONAL EXPERIENCE PLAYS A CRITICAL ROLE IN INITIAL DEVELOPMENT AND CONTINUANCE OF THERAPEUTIC ALLIANCE

SAFRAN AND GREENBERG 1991

THERAPIST PROCESS EMOTIONS EVOKED IN THEM BY PATIENTS IN A

� NONDEFENSIVE WAY

� POWERFUL WAY OF HELPING

� TO LEARN THAT RELATIONSHIPS WILL NOT NECESSARILY BE DESTROYED BY

� PAINFUL, AGGRESSIVE, OR POTENTIALLY DIVISIVE FEELINGS

� THEY CAN SURVIVE THESE FEELINGS

BION

� EMOTION PROVIDES A TYPE OF INTEGRATIVE FUNCTION OF BOTH HIGHER LEVEL ABSTRACT CORTICAL ACTIVITY WITH

� LOWER LEVEL BODILY FELT SENSE GENDLIN 1991

� IN ORDER TO BE EFFECTIVE, AN INTERPRETATION MUST BE EMOTIONALLY IMMEDIATE LEVENTHAL 1984; STRACHEY 1934

� SEEING THINGS FROM NEW PERSPECTIVE AS A WHOLLY INTEGRATED ORGANISM COMES FROM EMOTIONALLY IMMEDIATE AWARENESS IN THE PRESENT

ACCEPTANCE EXPERIENCING AND ACCEPTING THE

MULTIPLICITY OF SELF

BRINGING PARTS OF THE SELF INTO

DIALOGUE WITH EACH OTHER THROUGH

AWARENESS

THE SELF IS A PROCESS RATHER THAN A

SUBSTANTIAL ENTITY . BUDDHIST

PSYCHOLOGY

TO LET GO AND SIMPLY BE, RATHER

THAN STRIVING TO BE ANYTHING IN PARTICULAR

SURRENDER RATHER THAN SELF

MANIPULATION

HOPE FOR DESPAIR – FAITH (HELP PATIENT BRING DESPAIR AND

CYNICISM INTO THE OPEN AND MAKE IT A CONCRETE FEELING IN

THE RELATIONAL CONTEXT)

HOPE FOR DESPAIR – FAITH (HELP PATIENT BRING DESPAIR AND

CYNICISM INTO THE OPEN AND MAKE IT A CONCRETE FEELING IN

THE RELATIONAL CONTEXT)

HELP ACKNOWLEDGES THESE FEELINGS, FEEL PAIN, AWAKEN

UNFULFILLED YEARNING AND FEELS LESS ISOLATED

HELP ACKNOWLEDGES THESE FEELINGS, FEEL PAIN, AWAKEN

UNFULFILLED YEARNING AND FEELS LESS ISOLATED

IMPORTANT THAT THERAPIST BE AWARE OF POCKETS OF DESPAIR IN

ONE’S OWN LIFE –CONTERTRANSFERENCE

EXPLORATION

IMPORTANT THAT THERAPIST BE AWARE OF POCKETS OF DESPAIR IN

ONE’S OWN LIFE –CONTERTRANSFERENCE

EXPLORATION

BE AWARE THAT MOMENT OF HOPEFULNESS MAY IMMEDIATELY TRIGGER GUILT (AS UNPROCESSED ANGER AND RAGE ) AND BRING

BACK THE CYNICISM VERY QUICKLY-PATIENT MAY ARTICULATE SENSE

OF BEING “CONNED” –WITHDRAWAL INTO PUNISHING SELF FOR HAVING THE FEELINGS

BE AWARE THAT MOMENT OF HOPEFULNESS MAY IMMEDIATELY TRIGGER GUILT (AS UNPROCESSED ANGER AND RAGE ) AND BRING

BACK THE CYNICISM VERY QUICKLY-PATIENT MAY ARTICULATE SENSE

OF BEING “CONNED” –WITHDRAWAL INTO PUNISHING SELF FOR HAVING THE FEELINGS

RESISTANCE – ANY ASPECT OF PATIENT’S ACTIVITY –INTRAPERSONAL OR INTERPERSONAL THAT IS A CULMINATION OR COLLECTION OF DEFENCES TO WARD OF UNWANTED FEELINGS

ULTIMATE GOAL IS TO GET TO THE IMPULSE THAT IS DEFENDED AGAINST AND NOT JUST ANALYSIS OF RESISTANCE

ANXIETY IS SEEN AS A SIGNAL OF POTENTIAL BREAKTHROUGH OF DANGEROUS INSTINCTUAL IMPULSES – EGO’S RESPONSE TO PERCEIVED DANGER OF BEING OVERWHELMED

THE EXPLORATION OF RESISTANCE (AND NOT OVERCOMING IT) LETS THERAPIST AND PATIENT SEE THEIR ATTITUDES, BELIEFS, VALUES, WISHES, FANTACIES, AMBITIONS – HOW THEIR CHARACTER AND PERSONALITY HAVE BEEN STRUCTURED

NEUROSIS IS TYPICALLY ASSOCIATED WITH PARALYSIS OF THE WILL – RESULTING FROM FAILURE TO ACHIEVE IMPORTANT DEVELOPMENTAL TASK OF ACHIEVING A SENSE OF AGENCY –THE CREATIVE ACT OTTO RANK

THE ACT OF UNCONSCIOUSLY RESISTING THE EXPLORATION OF A PARTICULAR FEELING OR FANTACY CAN BE TRANSFORMED INTO THE ACT OF INTENTIONALLY DECIDING NOT TO DO SO IN THE PRESENT MOMENT

AMBIVALENCE, MAY NEED EXPLORATION, BEFORE THE EXPERIENCE THAT IS BEING DEFENDED AGAINST

OFTEN PATIENTS WHO FEEL COMPLETELY STUCK IN THEIR LIVES AND HAVE NO CAPACITY TO CHOOSE AND TO ACT IN ACCORDANCE WITH THEIR CHOICES, THE ABILITY TO WILL IN OPPOSITION TO THE THERAPIST CAN BE A CRITICAL TURNING PONT

THERAPY OFTEN INVOLVES REENACTMENT OF THE PATIENT’S TRAUMATIC DEVELOPMENTAL EXPERIENCE IN WHICH THERAPIST IS PULLED INTO PLAYING THE ROLE OF THE PERPETRATOR

SANDOR FERENZI 1932

01THE THERAPEUTIC RELATIONSHIP IS THE MECHANISM OF CHANGE

02CORRECTIVE EMOTIONAL EXPERIENCE

FRANZ ALEXANDER 1948

03

1

EMOTIONAL ATTUNEMENT AND ITS ABSENCE PLAYS AN IMPORTANT PART IN DEVELOPMENTAL PROCESS

2

THE LEVEL TO WHICH AN INDIVIDUAL INTEGRATES AFFECTIVE EXPERIENCES DETERMINES THE EXTENT TO WHICH SHE ULTIMATELY DEVELOPS A SENSE OF SELF THAT IS GROUNDED IN HER ORGANISMIC, BIOLOGICALLY ROOTED EXPERIENCE SAFRAN AND SEGAL 1990, DAN STERN 1985

3

IN HEALTHY MOTHER –INFANT DYAD, MOMENTS OF AFFECTIVE MISCOORDINATION ARE TYPICALLY FOLLOWED BY REPAIR IN THE INTERACTION

4

ONGOING OSSICILATION BETWEEN PERIODS OF MISCOORDINATION AND PERIODS OF REPAIR ULMITATELY HELP INFANT/PATIENT ADAPTIVE RELATIONAL SCHEMA

5

HELP PATIENT RECOVER SPLIT OFF PART OF THE SELF-PARALYSIS OF SPONTANEITY IS HELPED TO BE REPAIRED

� Use information about countertransference feelings as they can reflect therapist’s identification with patient’s internalized objects or with unconscious aspects of the patient’s self

� Projective identification – patient projects unwanted aspects of self onto therapist –one way or other nudges or coerces therapist to experiencing disowned feelings-into acting in accordance with the projection Ogden 1979, Klein 1975

� Therapist could reflect back the projection, contain the projection and help patient metabolize the experience – by experiencing the complex transference feelings -patient can recover disowned aspect of self in detoxified form

TRAP DESCRIPTION OF DISENGAGEMENT

� ASSESSMENT ASKING TOO MANY QUESTIONS – PASSIVE STANCE

� EXPERT COMMUNICATING ONE HAS ALL ANSWERS AND WILL SOLVE THE PROBLEM – PASSIVE STANCE OR DEFENSIVE

� PREMATURE FOCUS TRYING SOLVING PROBLEM BEFORE STRONG THERAPEUTIC RELATIONSHIP ESTABLISHED & FOCUSSING ON ISSUE BEFORE PATIENTS ARE READY MIGHT LEAD TO POWER STRUGGLE AND SUBSEQUENT DISCORD

� LABELING EMPHASIZING A DIAGNOSTIC OR OTHER LABEL ( ALCOHOLIC, DENIAL) COME ACROSS AS STIGMATIZING AND JUDGEMENTAL

� BLAMING PLACING FAULT - INCREASING DEFENSIVENESS

� CHAT SMALL TALK – INSUFFICIENT DIRECTION AND DISATISFACTION

� IN ABSENCE OF NEW EXPERIENCE, THERAPY REMAINS AN INTELLECTUAL EXERCISE

� RELATIONSHIP WITH THERAPIST LEADS TO NEW CONSTRUCTIVE EMOTIONAL EXPERIENCE CHALLENGING THE EXISTING RELATIIONAL SCHEMAS

� NEW AWARNESS OF INTERNAL EXPERIENCE THAT WAS DISOWNED AND MAY BE BEING PROJECTED ONTO THERAPIST OR PREVIOUSLY TAKEN PLACE OUT OF AWARENESS

� PRESENT AWARENESS OF SOME ASPECT OF ONE’S OWN CONSTRUCTION OF REALITY AS IT TAKES PLACE

� AWARENESS = IMMEDIATE ; INSIGHT = RETROSPECTIVE REFLECTION

� WE KNOW THINGS NOT JUST THROUGH OUR HEADS, BUT ALSO THROUGH ACTIONS AND OUR BODILY FELT EXPERIENCE

AUTONOMY OVER DECISION MAKINGAUTONOMY OVER DECISION MAKING

ELICITING MOTIVATION FOR

CHANGE

ELICITING MOTIVATION FOR

CHANGE

“ASK”“LISTEN”“INFORM”

“ASK”“LISTEN”“INFORM”

DEVELOP DISCREPANCY

(CURRENT BEHAVIOR AND LONG TERM

GOALS)

DEVELOP DISCREPANCY

(CURRENT BEHAVIOR AND LONG TERM

GOALS)

COST BENEFIT ANALYSIS

COST BENEFIT ANALYSIS

“CHANGE TALK” HIGHLIGHT

“CHANGE TALK” HIGHLIGHT

“ROLL WITH RESISTANCE”“ROLL WITH RESISTANCE”

� INTEGRATION OF AFFECTIVE INFORMATION WITH

� HIGHER LEVEL COGNITIVE PROCESSING

� IN ORDER TO ACT IN A FASHION

� THAT IS GROUNDED IN ORGANISMICALLY BASED NEED

� BUT NOT BOUND BY REFLEXIVE ACTION

GREENBERG & SAFRAN 1987; LEVENTHAL 1984

(1) FOCUS AND REPETITION,

(2) CREATING AND MAINTAINING A COLLABORATIVE ALLIANCE,

(3) INDUCING MODERATE LEVELS OF ANXIETY,

(4) FACILITATING MULTIPLE LEVELS OF EMOTIONAL ACTIVATION,

(5) CREATING “PROFOUND MOMENTS OF MEETING,” AND

(6) DEVELOPING A COHERENT LIFE NARRATIVE.

Coughlin, Patricia. Maximizing Effectiveness in Dynamic Psychotherapy

� Developed by Dr. Albert Ellis (Rational Emotive Behavior Therapy) and Dr. Aaron Beck

� The way people think in a specific situation will affect how they feel emotionally and physically, and will also alter their behaviour (and vice versa).

� E.g. The CBT model views panic attacks as catastrophic misinterpretations of normal bodily symptoms (Beck et al., 1985; Clark, 1986).

� In any consultation - identify and reflect back a patient’s key thoughts, feelings and behaviour, using empowering CBT-based explanations of problems, or gently encouraging positive behavioural change.

� Third wave of CBT has integrated the finding that focusing only on conscious thoughts is not effective and an evolving method that includes an increased focus on emotional awareness and regulation (Barlow et al., 2011) large study out of Sweden Holmquist, Strom, & Foldemo, 2014

� Increased empathy and shared understanding of difficulties

� Improved ability to understand and make sense of their problems

� Aids discovery of new coping strategies or solutions to problems

� Reduction in distressing emotional symptoms

� Better able to manage physical and emotional health (improved self-efficacy skills)

� Improved relationships with health professionals

� Improved symptoms (or reduced risk of deterioration)

� Reduced suicide risk

� Reducing prescriptions for antidepressant medications

� Reduced referrals to secondary care services

� Benefits in the workplace – reduced sick leave and better retention in employment

� Improved quality of patient-centred clinical care - increasing patient choice, experience and engagement.

� Increased confidence and skill in diagnosis and management of common psychological and emotional disorders

� Personal and job satisfaction

� Improved time management

� Able to use effective cognitive and behavioural strategies for facilitating change

� Helps understand and improve relationships with patients, including ‘heartsink’ patients

� Useful for coping with GPs’ own difficulties and problems

� Teaching, mentoring and clinical supervision

• Take on extra responsibility for solving patient problems

• Become a ‘mini’ cognitive therapist who can ‘cure’ complex patients in 10 minutes

• Change the patient’s mind or to persuade them around to the GP’s own way of thinking

• Use the approach with every patient in every consultation

� Keeping a realistic attitude

� Avoid ‘positive thinking’

� Leave consultations on an ‘open’ note

� Curiosity and genuine interest in the patient’s perspective,

� Appropriate questioning style, which does not feel like an aggressive interrogation.

� Collaborative partnership - Jointly identify, understand and overcome the patient’s difficulties

� Structured and problem-focused - Setting specific goals and monitoring outcomes

� Empower lasting practical skills in understanding and managing their own problems

� Time-limited and brief (usually 6– 20 sessions)

� Takes a ‘here and now’ approach

� Uses a questioning style - guided discovery

� Identify each patient’s unique viewpoint and beliefs

� Stimulate recognition of alternative, more helpful perspectives and ideas

� Behavioural experiments to test the accuracy of alternative beliefs

� Homework

Cognitive-behavioural model (CBM) for GP consultations (adapted from Padesky & Mooney, 1990; Williams & Garland, 2002)

� CBT teaches patients to view their thoughts as merely hypotheses or guesses to be tested against reality, rather than absolute fact.

� However, patients can learn to identify and test out whether their automatic thoughts represent a realistic assessment or whether another perspective may be more accurate and helpful.

� “What was going through your mind just then?”

� “What is it about this situation that really upsets you?”

� “I noticed that you became really [sad] just then, what were you thinking?”

ALL OR NOTHING (BLACK AND WHITE

THINKING

SHADES OF GREY

CATASTROPHIC THINKING KEEP REALISTIC VIEW OF FUTURE

WHAT IF ….? THINKING THE WORST MAY NOT HAPPEN!

EMOTIONAL REASONING YOUR EMOTIONS MAY BE CLOUDING

YOUR JUDGEMENT

BLAMING YOURSELF SHARE THE RESPONSIBILITY FAIRLY

SELF CRITICISM BE KIND/COMPASSIONATE TO SELF AND

OTHERS

MIND READING (HOW OTHERS SEE YOU) DON’T JUMP TO WORST CONCLUSION

IGNORING POSITIVE IGNORING POSITIVE

Unrealistic high standards HAVE FLEXIBLE AND REALISTIC GOALS

ALL OR NOTHING (BLACK AND WHITE

THINKING

SHADES OF GREY

CATASTROPHIC THINKING KEEP REALISTIC VIEW OF FUTURE

WHAT IF ….? THINKING THE WORST MAY NOT HAPPEN!

EMOTIONAL REASONING YOUR EMOTIONS MAY BE CLOUDING

YOUR JUDGEMENT

BLAMING YOURSELF SHARE THE RESPONSIBILITY FAIRLY

SELF CRITICISM BE KIND/COMPASSIONATE TO SELF AND

OTHERS

MIND READING (HOW OTHERS SEE YOU) DON’T JUMP TO WORST CONCLUSION

IGNORING POSITIVE BALANCING NEGATIVE AND POSITIVE

UNREALISITIC HIGH STANDARDS HAVE FLEXIBLE AND REALISTIC GOALS

• What is the evidence for this thought? What makes you think that?

• Is there any evidence against this thought? Does anything suggest it might not be entirely accurate?

• Is it logical or realistic? Is it fair?

• Is it a compassionate or kind way of looking at things?

• Is it an ‘unhelpful’ thinking style?

• What are the advantages and disadvantages of thinking this way?

• What advice would you give to someone else in this situation?

• Is there another way to view the situation that takes all of this new evidence into account?

� SIMPLE DISTRACTION TECHNIQUES

� A SEVERITY SCALE TO PUT MINOR PROBLEMS INTO PERSPECTIVE; USE HUMOUR AND BE CREATIVE

� IMAGINE VIEWING THE SAME SITUATION IN 5 OR 10 YEARS’ TIME.

� DIARY TO RECORD THOUGHTS THAT ARISE IN CHALLENGING SITUATIONS,

� PRACTISE AT HOME USING A CBT-BASED SELF-HELP BOOK OR WORK WITH ACBT THERAPIST

� ‘Feelings’ are viewed as emotions or moods – they are usually one word

� -“What did feeling ‘upset’ mean for you in this situation? Are there any other ways to describe how you felt?”

� happy, excited, angry, sad, frustrated, embarrassed, fearful

� Some common negative feelings include: • sadness and loss, e.g. feeling low, down, unhappy, depressed, miserable, sad, fed up, disappointed

� guilt and shame, ashamed, guilty, embarrassed, humiliated, mortified

� anxiety and fear, nervous, tense, frightened, anxious, worried, afraid, scared, panicky, terrified, petrified

� anger and hurt, annoyed, irritated, frustrated, cross, exasperated, angry, furious, mad, livid, infuriated, hurt

Useful to record any changes in intensity of feelings when the patient tries a new strategy to cope with their problems.

• “What do you make of all this…?”

• “Does this help you see things any differently?”

• “What have you learned/ understood from our time together today?”

• “What might you say to a friend in the same situation?”

• “What do you conclude from our discussion? How could you test those conclusions?”

• “Are you surprised by anything you see here?”

“I will be very interested to hear how you get on. We can’t be certain what will happen, but we can always learn from it, and use it to plan what to try next.”

IT IS A”NO LOSE” EXPERIMENT

. • Taking away a copy of the CBM chart to reflect on and add to further.

• Reading a self-help CBT book or leaflet relevant to their specific difficulties.

• Recording relevant information, such as keeping a diary of thoughts and feelings in different situations.

• Behavioural experiments such as increasing exercise or pleasurable activities, or graded exposure to anxiety-provoking situations.

� CBT is not simply thinking positively – it is about realistic thinking

� Changing behaviour - to break negative cycles - improve a patient’s symptoms.

� Distraction

� Broadening perspectives on difficult situations

� Environment, early experiences, social circumstances and culture

FURTHER TECHNIQUES

� Behavioral activation

� Mindfulness - Distance from thoughts

� Behavioral experiments

� powerful evidence for changes in thoughts or beliefs.

� test out new beliefs and approaches to problems in real life,

� Involving patients in behavior changes

� Setting realistic expectations

� Current time Like to get to

� EIGHT STEPS OF PROBLEM SOLVING

� * LIST * CHOOSE * DEFINE * GENERATE SOLUTIONS * CHOOSE * ACTION PLAN

* ACTION * REVIEW*

� Normalize symptoms – panic attacks are not life threatening

� Bibliotherapy : www, books

� Establish realistic expectations ( to improve, not cure)

� CBT is likely to be helpful in reducing distress

� Lifestyle advice: decrease excessive use of caffeine, alcohol, nicotine, chocolate ( alchol/marijuana used to decrease anxiety can precipitate panic/anxiety in withdrawal)� Minimize use of sedatives, hypnotics� Regular exercise

� http://mediasite.otn.ca/Mediasite/Play/768d27bff3874be3bf5ff2d05608ffae1d

� http://sunnybrook.ca/content/?page=frederick-thompson-anxiety-disorders-centre

� http://www.ptmg.com/meeting-details/Medical-CBT-for-Depression-Ten-Minute-Techniques-for-Real-Doctors-(Kitchener-Waterloo,-2017)-Kitchener----356706

� Cognitive Behaviour Therapy (CBT) Certificate Program

� http://www.camh.ca/en/education/about/AZCourses/Pages/CBT-Info-Page.aspx

� http://www.mindovermood.com/

Thanks to Dr. Lee David MB BS, BSc, MA (CBT), Member of R C G P and

Guilford Publications Negotiating the Therapeutic Alliance Safran and Muran