Counseling of depression in primary care在基層醫療層面作抑鬱症輔導

Dr. Alan Syed 陳韋銘醫生香港大學內外全科醫學士香港中文大學家庭醫學文憑香港中文大學男性健康文憑香港大學社區精神醫學深造文憑

Evidence based counseling

Cochrane Database Systemic Review (2007) Psychosocial interventions by GP Main results: There is good evidence that problem-solving

treatment by general practitioners is effective for major depression. 解决問題治療

Level 1 evidence that problem solving treatment by a GP is no less effective than antidepressant treatment on depression, psychological symptoms and social functioning.

Caution: 2 studies, conducted by same research team, 30 to 40 patients group, were treated by experienced and highly trained research GPs, which limits the translation to general practice.

Huibers M, Beueskens A, Blejenberg G, Schayck Cp V. Psychosocial interventions by general practitioners. Cochrane Database Sys Rev. 2007 Jul 18;3:CD003494.

Function of counseling Central function of counseling

is to help clients to recognize their own strengths 力量 and clarify what kind of person they want to be (Corey, G.)

Help clients to learn to take actions for solving problems of living and grow psychologically (David Ho et al) 幫助病人解决生活上的問題和心理成長

Goals in primary care setting

Supportive counseling Reattribution Psychoeducation Crisis intervention Problem solving Symptoms amelioration: anxiety, depression, anger

Enabling the person to : Better utilize and develop his/her ability and resources 利用資源 Enhance self esteem, self confidence and self discipline 增加自信 Make better choices 更好的選擇 Be more responsible for himself/ herself Have better self understanding and acquire more peace within Build up harmonious and meaningful relationship with others

Some beliefs about counseling(Based on Satir Model)

Everybody has the ability to change for betterment Change is possible, and HOPE is the significant factor for chan

ge 改變是有可能的，希望對改變十分重要 We cannot change the past, but we can change its impact on

us 我們不能改變過去，但能改變過去對我們的影響 We all have internal resources (strength) we need to cope suc

cessfully and grow The problem is not the focus in counseling, helping the perso

n to cope better with the problem is the problem( find the ability and strength)

The problem of an individual needs to be understood and resolved in a systemic perspective.

Counseling theories

Understanding human being and its function Human functioning is influenced by: Physical, mental, emotional , social, cultural, political

and spiritual dimensions Balanced integration of physical, emotional, mental,

existential and spiritual level of consciousness (meaning of life) to achieve an optimal health.

A holistic approach= healing at different levels

Counseling of depression

All approaches basically to help the patient to change thinking and behaviors

Frequent used approaches Family system therapy Person Centered Therapy Existential therapy Reality therapy Cognitive behavioral techniques Mutimodal therapy

The counseling process overview

1. Connecting-relationship building 2.Assessing- the presenting problem and its impact on the person

3.Intervening – Goal setting – facilitating change

4.Consolidating - Anchor change – closure 例如：〝我好佩服你！〞

Therapeutic tool- Satir Model

Some other therapeutic toolsBased on Choice theory ( New reality Therapy)

Three Major aspects of Choice Theory Basic needs Quality World Total Behavior

Basic Needs (self worth) Survival 生存 Love and belonging 愛與歸屬 Power 權力 Freedom 自由 Fun 樂趣The Quality World In one quality world, one creates and stores pictures of: 1) the people we most want to be with 2) the things we most want to own or experience 3) the ideas or systems of belief that govern most of our behaviors

A Case to share:The patient’s presenting problem

Mrs. Lam presented with right jaw pain and numbness of the right face for few days. She attributed to fish poisoning. She was worried that she had a serious problem which required surgery for treatment.

She had symptoms of depression: poor appetite and weight loss of 5 pounds. Insomnia with early morning waking for two weeks Depressed mood for a month Feel anxious with tightening of fists and clenching when she

woke up in the morning. Guilty feeling after she hit her son when she was upset. Loss of interest.

She has excessive worries to her health, her son’s education. Her husband was out of job recently and she worried about the mortgage.

Famliy genogram

Patient 34 year old, school counselor

husband’s father 64, passive aggressive

Simon 7yr old, poor school performance

patient’s mother , 60,abusive to her children

David 5year oldSmart, intelligent

Jane, 40 Major depressive disorder

Mary, 36, Major depressive disorder

Mr. Lam, 35, IT manager, out of job

63 yr old well

Mr.Wong, died 2 yrs ago CVA

Background history

Mrs. Lam, 34 years old, married, a school teacher with two sons. She had depressed mood for a month because of the poor relati

onship with her husband, they did not have sex for 6 months.(interpersonal problem)

She remembered her husband did not go to the hospital immediately when Simon was born, she rang him up and he told her that he was playing video games at home.(living in the past)

Last year her father in-law gave her a lot of pressure when Simon applied for primary school admission, he only allowed Simon to go to the La Salle College primary school. (constrictive rules)

She herself wanted Simon to have good school results, she was upset if he did not get high marks at examinations. She would hit him when she got irritable from teaching him. (unrealistic expectation)

Problems identifiedDysfunctional beliefs Her belief was that if Simon did not have good school results, she would be a bad mother.

Unrealistic expectations As a teacher in a special school for children with behavioral problems; she expected the kids to learn like a norm

al child.She had a high level of frustration from her unrealistic expectations.

She projected her frustration to Simon when she taught him at home.

Interpersonal relationship For many years she blamed her husband for no “action” at anniversaries of their marriage.

She remembered her husband did not go to the hospital immediately when Simon was born, she rang him up and he told her that he was playing video games at home.(memories of unhappy experience)

Communication problem to anger and violence Recently she wanted a divorce because she felt demoralized when she took her mother in-law to massage and paid for the fe

e but her husband did not appreciate what she did. She asked him back for the money, he refused and they had a fight.

Stressors Her husband, an I.T. manager, was redundant from his company recently.

The mortgage accounted for 50% of her salary.

Biopsychosocial model Biological The etiology of the depression included genetic and biological factor, the

cause was deficiency in neurotransmitters in the brain.

Psychological The somatic presentation is a means of escaping from problems or a

psychological response or manifestation of emotional stress. The problem included cognitive, maladaptive coping behavior and

interpersonal relationship.

Social Mr. Lam lost his job, There is a financial burden and she did not have any confide to share her feelings apart from her elder

sister with whom she has a better relationship

all these contributed to her emotional problem.

Interpretation with Family context

Family as a system In this hierarchical family, there are constrictive

rules. “Grandpa must dominate”, especially over his

grandsons’ education, “differences are bad” and “change is to be resisted”

gave Mrs. Lam a lot of stress because of restricting freedom of expression.

The family had a closed system in which everyone is supposed to have the same opinions, feelings, and desires whether or not this is true.

Members in this hierarchical system lack tolerance for difference and uniqueness which cause emotional and behavioral disturbance.

Family dynamics

(A) Family structure An extended family (B) Family function The family was dysfunction when Simon was born, at application for Simon’s primary school education and when Mr. Lam lost his job. There is disturbance in role, status, power, or

unhappy events at certain stage of family life cycle. The dysfunctions arise from poor ability to cope

and solve problems.

Dysfunctional communication (Satir Model)

With constriction of the Self by restrictive rules, unrealistic expectations and inappropriate roles comes defensive communication into four styles of survival coping stances: placating, blaming, being super-reasonable, and irrelevant.

The patient used placating mode caused her to repress her anger towards her father- in -law and manifest physical symptoms.

She used the blaming mode towards her husband.

Family dysfunction with the metaphor of the personal iceberg

Mr. Lam lost his job hence his role changed. Instead of being a bread winner, he did the domestic work, took children to school. His status lost, perceived the grief with low self esteem therefore he did not interact with his wife.

Simons learned from the family triad, through his parent arguments, he perceived himself as useless, valued with low self esteem. He behaved poorly at school because he yearned for his parents love, they help him with revision together.

Mrs. Lam was not happy that her husband did not come to hospital early (unmet expectation). She perceived her husband did not love her, valued with low self esteem. She had the feeling of grief, entered sick role (behavior) with emotional disorder.

What have been done apart from the usual care?

Management (usual care) Exclude organic course By detailed history, physical

examination, and investigations including ESR, thyroid function test.

Management of depressive disorder

Prescribing SSRI.

Counseling for emotional problems

To establish a therapeutic relationship To develop rapport with genuineness, unconditional posi

tive regard and respect, empathic understanding and trust, facilitate communication by active listening, picking verbal and non verbal cues.

It is the therapist’s attitude and belief in the inner resources of the client that create the therapeutic climate for growth.

BOZARTH, J. D., Zimring, F.M.& Tausch, R.(2002). Client-centered therapy: The evolution of a revolution. In D. J. Cain,& J. Seeman, (Eds), Humanistic psychotherapies: Handbook of research and practice (pp147-188). Washington, DC: American Psychological Association.

Assessment

With the understanding of the patient’s life cycle and family dynamics, explore the patient’s current emotional status (worries and concern).

Identify contributing factors for the emotional disturbance by exploring

the present family situation, work environment, sexual behavior and financial situation.

To establish a shared understanding of the problem and contributing factors with the personal iceberg metaphor of the Satir model including feeling ,perception, expectations, yearning, behavior, coping reassure her that her symptoms are not organic and it represents an emotional problem.

Exploring the”personal iceberg” metaphor in the Satir model Exploring the behavior Doctor: What behavior do you want to change? Lam: I would like to stop scolding my husband or hit him when he did not do what I expected, for example, watch over our son’s homew

ork Exploring feelings Doctor: What feelings do you experienced when that happened? Lam: I feel angry. Exploring feelings about feelings Doctor: “How do you feel about feeling anger with your husband?’ Mrs. Lam: I feel I am useless. Exploring perceptions Doctor: “What was your interpretation that your husband did not do what you expected?” Lam : He did not love me anymore. Exploring meaning Doctor: “What meaning are you giving to this situation to mean to you?” Lam : He does not care about my feelings. Exploring beliefs Doctor: ‘Do you believe you have a choice in this situation?” Lam : I believed so. Doctor: What beliefs are you holding that are influencing your feelings? Lam: If he really loved me, he would see what needed to be done and do it Exploring yearnings “What is that you long for from your husband?” Lam: I am yearning for acknowledgement. Exploring expectations What expectation are you holding that are influencing your feelings? He should know that how hard I am working in school and help out

Exploring the following

Impact Past attempts to solve problems Crisis Relationship with family Resources and limitations Capacity and readiness to change Frame of reference-FOO Supporting network inside and outside

family

Intervention-Goal setting

Use a collaborative approach negotiating a common realistic goal.

The goal of counseling (the Satir model) is to improve self esteem which is the basic element in dysfunctional family behaviors.

Counseling techniques used

(1) Cognitive therapy (2) Behavioral modification (3) Information giving (4) Stress management (5) Psychoeducation (6) Communication skill training (7) Satir model (microskills) (8) Coping skills training (9) Choice theory

(1)Cognitive restructuring

Identify automatic thoughts

Challenge automatic thoughts and perceptions and dysfunctional behaviors by socratic questioning

Replacing automatic negative thoughts with rational and useful thoughts

(2) Behavioral modification

Learn adaptive coping skills, find resources and strength as each person contains

all the resources one needs for growth and healthy functioning.

Teach the patient to avoid using maladaptive survival stance coping skills including placating and blaming,

use skills to improve awareness, acceptance of our own feelings which would promote high self esteem in a harmonious way with the aim to become congruent.

Activity scheduling-Focus on pleasant activities, rate the sense of achievement, use of dairy to record accomplished activities

(3) Information giving

Change is possible and we have choices.

Hope was a key source of resources for facilitating change.

Problem is not a problem , coping is the problem

(4) Stress management

Identify the source of stress Previous coping strategies relaxation exercise assertive skills

Relaxation techniques with controlled breathing, progressive muscle relaxation guided imagery

(5) Psychoeducation

Doctor: Given your history of family stress, your symptoms were of an emotional basis, accordingly the DSMIV, it is a major depressive episode, caused by a deficiency of neurotransmitter in the brain which could be corrected by SSRI.

The interpersonal problems complicated your illness, counseling or psychotherapy help you to see the relationship and interactions between thoughts, feelings and behavior and the physiological symptoms.

(6) communication skill training “Communication is to relationships what breath is to life, so schedule a time each day to talk to each other.

Tell your husband what you want “ I wish that you could ring me up during the day.”

Avoid Deadly habits that destroy relationship Criticizing 挑剔 Blaming 指責 Complaining 埋怨 Nagging 嘮叨 Threatening 威嚇 Punishing 懲罰 Bribing or Rewarding to control 賄賂或用獎賞來操控

Learn caring habits that nurture relationship Supporting 支持 Encouraging 鼓勵 Listening 聆聽 Accepting 接納 Trusting 信任 Respecting 尊重 Negotiating difference 協商

(7) Microskills (Satir Model) 維琴尼薩提爾

Make contact

Reaching out by eyes contact, facial expression (connect- log-on)

Attending, active listening Observe the posture, eyes, facial

expression Observe verbal and non verbal cues

Microskills-Validating to create a sense of safety

Engendering hope Mrs. Lam: He hit me, I wanted a divorce Doctor: Although it feels pretty hopeless now, I see new possibiliti

es for you, there are other alternatives we can explore. 現在看起來好像沒有希望，但我看到有其他可能性，我們可一起探討。

Affirming resources Doctor: Are you aware of the strength and courage you talked ab

out your problems today? I remind once again of your capacity to change. 今天你將你的問題說了，這表示你有勇氣和力量去改變自己。

Normalizing Doctor: All couples will go though disappointment after marriage.

每對夫婦在結緍後都會遇到失望的經瀝。

Other microskills

Reflection of feelings Doctor: From what you are saying, I am hearing

that you feel pain about what is happening in your marriage 聽了你的故事，我聽到你的婚姻生活帶給你的痛苦

Reframing Doctor: I see that the members of this family ar

e wanting good things to happen but not knowing how to make that happen. 我看到這個家庭的成員很希望有好的事情發生，但只是 知怎樣去做

Microskills:Defusing Blaming and Guide to change

Doctor : Now that you have put an expectation on your spouse that does not fit, are you willing to let go of that? 你會不會捨棄你不合理的期望

Doctor: On reexamination of you expectation and beliefs, what changes do you want to make? 在重新思考後，你想怎樣改變？

Lam: I would like to stop making negative generalizations about my husband. I would like to stick to the issue at hand and ask for help in a non-reactive manner. 我想停止對我先生負面「以片盍全」的想法，用一個非反應性的方法去求他幫我解決問題？

Microskills: Shifting from content to process

P:“ My father in law is driving me crazy on choosing a school for Simon.”

D: How have you two dealt with other differences? 你們怎樣處理你們其他的分歧和爭論？

P: What other ways does Simon aggravates you? “ Simon is out of control. He did not show any obedience.

” D: “What do you mean by obedience?” D: “How did people show obedience in your family when y

ou were growing up?”

Microskills: Identify the Dysfunctional process

“What I see is that, Mrs. Lam, you are living the life of a victim, blaming others especially your husband and looking backward instead of forward.

With the negative aspects of your life, which you did by dwelling on your major symptoms: depression, anxiety, inability to sleep, and other psychosomatic symptoms.

Cognitive restructuring-modify the blocked resources

When Mrs. Lam resources were being blocked by restrictive rules, inappropriate roles or unrealistic expectations, cognitive restructuring would modify these blocks.

Microskills: Challenging interpretations by cognitive restructuring

Doctor: Could you think of other possibilities that your husband did not go to the hospital immediately after Simon was born?

Mrs. Lam: He could be afraid of the hospital environment; he could have anxiety when it was the first time he became a father: he worked at home to meet a deadline, he just finished and was playing with the video game.

Microskills: Cognitive restructuring on irrational belief

“I must to follow the rules of the family otherwise I am unlovable.”

“I prefer to follow the rules of the family ,if not I am still a lovable person”

“Simon must do well at school otherwise I am a bad mother”

“I prefer Simon to have good results, I have done my best to be a good mother.”

Microskills: Freeing the SelfModifying restrictive rules

Mrs. Lam “I must obey grandpa rules” Doctor: You should say “I can choose how I

want to meet the needs of my family, sometimes I can choose my children’s needs and sometimes I can choose my needs”

Microskills: Modifying unrealistic expectations I attempted to elicit the unspoken expectations for her

parenting, knowing that many conflicts originated at the level of expectations.

Recognizing how vulnerable children are to being objects of their parents’ projections with the following parent –child relationship:

Make the parent feel worthy, by achieving or performing

Want and like the same thing the parent does Want to do what the parent wants Parent the parents Be a diversion so that their martial conflict can be

denied Lam: These were the reasons I got frustrated with

teaching Simon.

Microskills: Broaden perspectives

When yearnings are not met and people are carrying dysfunctional rules, roles or expectations, they will have limited perspectives.

I let her know that perceptions are the product of their own process, not external events.

Teaching new behaviors- maladaptive coping gives low self esteem

Placating disregard our own feelings of worth and say yes to everything, denies self respect and give people the message that we are not important.

Blaming is an incongruent way of reflecting constrictive rules, we should stand up for ourselves, not accept excuses, inconvenience or abuse from anyone. To blame is to discount others.

Microskills: Treasure huntAppreciate partner at least once a day

Detective hat- make sense Golden key- new possibilities Yes no medallion- boundary definitions Courage stick- overcome difficulties Wishing wand- provide energy for overcoming g

reat challenges Wisdom Box- guided towards wholeness/huma

nistic Heart (Jean Mclandon)- essential for congruenc

e

(8) Coping skills training Assertive Training Focused on her negative self statement, because

she did not think she had the right to ask what she wanted,

She succeeded in saying “no” to her father-in-law demand and expressed her viewpoint.

Use verbal, vocal and body message sub-skills ‘I’ statement and say ‘No’ Speak in a calm, firm voice, good eye contact,

avoid threatening gestures- finger pointing Via modeling and role-playing

Increase social interaction Identifying factors that are contributing to low social

interaction For example, getting into habit of doing things alone Feeling uncomfortable due to few social skills Deciding on activities that needed to be increased:

calling friends to suggest getting together Decreased watching television- increase social

interaction Graded task assignment Self reward Decreasing rumination and excessive self focus

Problem solving skills Doctor: You could identity the problem,

list all possible solutions, pro and cons of each possibility, choose best strategies, set a plan for implementation and evaluate.

Lam: For the mortgage, I could re-schedule the mortgage or sell the apartment and rent a house for the time being.

Anger management Doctor: Anger is a result of threat, fear or

unmet expectation. You should aware, acknowledge, accept, own, control and express your anger in an appropriate manner.

Acceptance of others. Go away from the scene when you have

signals of anger. Think of other possibilities positively.

(9)New Reality therapy 現實治療法 - based on Choice theory 選擇理論 What do you want? If what you are doing now does not get you what you want, do you want

to change?

Use three major aspects of choice theory to promote change Identify Basic Needs Discovering client’s Quality world Help client understand she is choosing the Total behavior that are the

symptoms

Information Better choice is available Things do not just happen Plan to make better choices Take much more effective control of her life

Choice Theory (New reality therapy) Lam: “I feel depressed much of the time, anxious at night and

overcome by panic attacks” Doctor: I let her know that I was more interested in what she is

doing and thinking because these are the components that can be directly changed

Her depressing is the feeling part of her choice, she can take a different action which is likely to change her depressing

experience

“You can only control yourself”

She come to realize that she does not have to be a victim of her past unless she choose to be and she had reharshed her misery enough.

She learned that most of her symptoms and avoidance keep her from what she want.

She realize that she has little control over changing others but has great deal of control over what she can do now.

Anchoring Change

Last visit-Experiencing greater self esteem Her eyes are bright and lively. Face –relaxed Relaxed jaw Smiling- “ Our family went to church together then we went to the beach together.”

Consolidating the change“KISS” Keep Improve Stop- deadly habits Start- start caring habits

Anchoring change Anchoring the change at the whole person level, not just behavioral or perceptual change Positively reinforce the change by verbal and non- verbal techniques

“how wonderful that you two can now be with each other in this new way.”

How would you follow up this patient in the future?

Anchor change Promote congruent living Mutimodal approach- BASIC-ID Encouragement/ empowerment See husband for couple therapy CB strategy/ CBT Refer to psychiatrist Refer to counseling specialist Refer to psychologist Refer to family mediation specialist

Mutimodal therapy

Comprehensive, systematic, holistic approach to behavior therapy

Technical Eclecticism Assessing the BASIC ID Lazarus, A.A. (2000). Mutimodal strategies with adults. In J. Carlson & L. Sperry (Eds.), Brief therapy with individuals and couples (p106-12

4). Phoenix: Zeig & Tucker.

A major premise of mutimodal therapy is that breath is often more important than depth.

The more coping responses a client learns in therapy, the less are the chances of relapse.

Lazarus, A.A.(1996). Some reflections after 40 years of trying to be an effective psychotherapist. Psychotherapy, 33(1), 142-145. Lazarus A. A. (2000). Mutimodal therapy. In R. Corsini & D. Wedding(Eds.), Current psychotherapies (6th ed., pp340-374). Itasca, IL: F.E. Pea

cock.

Mutimodal approach

Behavior Refers overt behaviors- observable and measurable What would you like to change? What would you like to stop and start doing? What are some of your main strengths? What specific behaviors keep you from getting what you want?

Affect What makes you laugh? What makes you cry? What emotions are problematic to you? Sensations Do you suffer from unpleasant sensations? Imagery- the way we picture ourselves How do you see yourself now? How would you like to able to see yourself in the future? Cognition What are the negative things you say to yourself? What are the main ‘should’ and must in your life? Interpersonal relationship What do you expect from the significant people in your life? What do they expect from you? Drugs/Biology- include nutritional habits and exercise patterns Are you healthy and health conscious? Do you take prescribed drugs? What are your habits pertaining to diet, exercise and physical fitness

Long term goal

Congruent living 和谐生活 To communicate clearly cooperate vs compete empower vs subjugate use authority to guide and accomplish to love ,value and respect themselves fully personally and socially responsible to use problems as challenges and opportunitie

s for creative solutions

Thank you