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

Dr Helen P Hamer RN, PhD, FNZCMHNSenior Lecturer/Nurse ConsultantSchool of Nursing & Centre for Mental Health ResearchUniversity of Auckland

h.hamer@auckland.ac.nz

School of Nursing

• 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

Living well: Basic principles

• Hope• Self-responsibility• Self-advocacy• Education• Meaning – purpose – direction• Support

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).

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).

• How do representations of illness shape health responses and behaviours?

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

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 stress and more able

to adopt health-promoting behaviors and attitudes.

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 salutogenic orientation (Antonovsky, 1979)

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)

• 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

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.

• 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.

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

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

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

• 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

5 PART MODEL (Padesky & Mooney, 1990)

thoughts

biology

behavior

moods

situation

historyculture

beliefs

context spiritual

Person’s environment

THE BASIS OF THE CBT MODEL

• “It is not the events themselves that disturb us, it is our interpretation of those events”

• (Epictetus)

Three levels of thinking

• Automatic thoughts• Underlying assumption or rules for living• Core beliefs (schema)

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”

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

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”

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”

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

• 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

• TARGETS:LOWERED MOTIVATIONDECREASED ACTIVITYANHEDONIA

Becoming Active Again

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

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).

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

Self-efficacy

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