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Cognitive  Therapy In  Palliative  Care  Settings
 

Cognitive Therapy In Palliative Care Settings

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    Cognitive  Therapy In  Palliative  Care  Settings Cognitive Therapy In Palliative Care Settings Presentation Transcript

    • Cognitive Therapy in Palliative Care Settings Professor Craig A White Macmillan Consultant in Psychosocial Oncology Depute Director of Psychological Services Lead Clinician, NHS Ayrshire and Arran Palliative Care Managed Clinical Network Lead Clinician, Supportive and Psychological Care, West of Scotland Cancer Network
    • Overview • P re va iling mode ls to unde rs ta nd ps ychologica l e xpe rie nce a nd ps ychopa thology • Outline of the cognitive mode l • S ome diffe re nce s in pa llia tive ca re s e ttings • Cha lle nge s to imple me nta tion • P ra ctice ba s e d e xa mple s • Dis cus s ion
    • Helgeson et al (2004) • 20% small but significant improvement • 27% high distress, rapid improvement 13/12 • 12% high distress, steady increase to 19/12 • 43% consistently low distress • 60% no dramatic change 4-13m
    • White, CA and Trief, P (2005) Psychotherapy for Medical Patients. In G Gabbard, J Beck and J Holmes. Oxford Textbook of Psychotherapy. Oxford: OMP. • P s ychodyna mic • Cognitive Be ha vioura l • Fa mily S ys te ms • Group P roce s s • Me dica l/Biologica l
    • Psychodynamic • Illne s s a s cha lle nge to s e ns e of s e lf • Ea rly s e lf de fine d by e xpe rie nce tha t yie lds conflicts whe n ill • De pe nde ncy • Conflict with a uthority • S e pa ra tion , Aba ndonme nt a nd Trus t • Ta ckle ‘de fe nce s ’
    • Family Systems • Le ve l of cohe s ion or e xte nt of conflict • Communica tion s kills , proble m s olving a bility a nd conflict re s olution • Va ria nce in illne s s re pre s e nta tion a nd s tra te gie s for ma na ge me nt of cha lle nge s
    • Cognitive Behavioural • Illne s s a s critica l incide nt • Illne s s a ppra is a ls me dia ting cha nge d e motion a nd be ha viour • Illne s s re pre s e nta tion • He lple s s ne s s /Controlla bility • Coping - Emotion Focus e d /Avoida nce • Intrus ive Me morie s of Illne s s • Tra its s uch a s optimis m or a nxie ty • Atte ntiona l bia s e s
    • Farber, G,Levin, T and White, C.A. (2005). A cognitive therapy conceptualisation of panic disorder exacerbated by interferon treatment. General Hospital Psychiatry, 27, 329-337. • Von Wille bra nd dis e a s e • He pa titis C tre a te d with inte rfe ron a lpha • S e ve re e xa ce rba tion of pa nic dis orde r • Ca lling 911, vis its to ER • Biologica l ps ychia try conce ptua lis a tion
    • “ It is accepted that the physical and psychological functions of patients with the same medical conditions vary widely. There is a huge variation in the subjective impact of medical conditions of the same objective severity. Two patients may have the same degree of physical disease or damage but yet have markedly different psychological responses to that physical illness” White, C.A. (2001). Cognitive Behaviour Therapy for Chronic Medical Problems. A Guide to Assessment and Treatment in Practice. Chichester: Wiley.
    • Generic Cognitions in Chronic Disease Evers et al. (2001), Journal of Consulting and Clinical Psychology, 69(6), 1026-1036 Study of patients with RA (n=263) and MS (n=167) Propose 3 generic illness cognitions  Helplessness that emphasises aversive meaning  Acceptance that diminished this  Perceived Benefits that adds positive meaning to disease
    • White and Unwin (1998) British Journal of Health Psychology, 3, 85-93 • Variance in post operative psychological morbidity accounted for (68%) by knowing how patients thought about their stoma • I am still a complete person despite my stoma • My stoma rules my life • I feel that I am in control of my body following my stoma operation
    • Cognitive Layers • Core beliefs are global, absolutistic beliefs • Assumptions are cross situational beliefs which can be thought of as rules for living • Automatic thoughts are situation specific • Each ‘ layer’ of cognition relates meaningfully to the next
    • Examples CORE BELIEFS Cancer means death; I am helpless, Others pity me ASSUMPTIONS If the cancer can’ t be cured, then I have nothing to live for; If I make plans then I will not be able to carry them out; I must hide my feelings AUTOMATIC THOUGHTS This is it, I am going to die; I can’ t be bothered; Everyone is looking at me; They all look so ill - I’ ll crack up if I end up like that
    • Principles • Eve r-e volving formula tion in cognitive te rms • S ound the ra pe utic a llia nce • Empha s is on colla bora tion a nd a ctive pa rticipa tion • Goa l orie nte d a nd proble m focus e d • Educa tive , with e mpha s is on s kills a nd re la ps e pre ve ntion • Aims to be time limite d • S tructure d s e s s ions • Te a che s ide ntifica tion , e va lua tion a nd re s pons e to dys functiona l thoughts a nd be lie fs • Va rie ty of te chnique s to cha nge thinking mood & be ha viour
    • The Cognitive Therapy Model Situation The following slides are adapted from Judith S. Beck, Cognitive Therapy: Basics and Beyond, 1995. New York: Guilford Presas
    • The Cognitive Therapy Model Situation Automatic Thought
    • The Cognitive Therapy Model Situation Automatic Thought Reaction
    • Lacroix et al. (1991) Health Psychology, 10(4), 268-273 Symptoms Reported • Choking sensation • Runny Nose • Headache • Sore Throat • Shortness of Breath • Back Pain • Muscle Pain and Soreness • Dizziness • Skin Rash • Fatigue
    • Lacroix et al. (1991) Health Psychology, 10(4), 268-273 Patient Groupings • SOB, fatigue, choking, runny nose (cold) • SOB (chest muscles tired) • Headache (unknown) • Back pain and sore muscles (improper wheelchair positioning) • Skin rash (dry skin) • Dizziness (moving too quickly)
    • Lacroix et al. (1991) Health Psychology, 10(4), 268-273 Physician Groupings • Sore throat, choking and runny nose (tracheotomy) • SOB (respiratory failure) • Back pain and muscle pain (spinal injury) • Skin rash (medication side effect) • Headache and fatigue (depression) • Dizziness (Brain injury)
    • Case Conceptualization Historical Info Core Beliefs Assumptions Compensatory Strategies Situation # 1 Situation # 1 Situation # 1 Automatic Thought Automatic Thought Automatic Thought Meaning of A. T. Meaning of A. T. Meaning of A. T. Emotion Emotion Emotion Behaviour Behaviour Behaviour * Adapted from Judith S. Beck, Cognitive Therapy: Basics and Beyond, 1995. New York: Guilford Press
    • Example of Proximal Formulation Childhood and Historical Info Core Beliefs Assumptions Compensatory Strategies Situation Automatic Thought Meaning of A. T. Emotion Behaviour Adapted from Judith S. Beck, Cognitive Therapy: Basics and Beyond, 1995. New York: Guilford Press
    • The Cognitive Model ENVIRONMENT Physical effects of cancer or its treatment, reactions of family etc. PERSONAL MEANING PHYSIOLOGY EMOTION BEHAVIOUR
    • Applying the Cognitive Model • As s e s s me nt us ing the cognitive mode l • Ca s e formula tion tha t a ccounts for the links be twe e n the s e e le me nts • Inte rve ntion a nd Eva lua tion of Outcome
    • Phases in Cognitive Therapy Engage • S ymptom Re lie f • Ma ximis e Qua lity of Life • Te a ch cognitive mode l • Encoura ge e motiona l e xpre s s ion
    • Phases in Cognitive Therapy Engage Cognitive Emphasis • Te a ch us e of Thought Monitoring • P roble m S olve le s s pre s s ing is s ue s • Ra nge of cognitive ly ba s e d s tra te gie s • Addre s s e nvironme nta l a nd s ocia l fa ctors
    • Phases in Cognitive Therapy Ending Engage Cognitive Therapy Emphasis • Re la ps e pre ve ntion • P la nning for the future • Ide ntify unde rlying a s s umptions a nd core be lie fs
    • Phases in Cognitive Therapy Ending Engage Cognitive Maintenance Therapy Emphasis • Imple me nta tion of re la ps e pre ve ntion • Boos te r s e s s ions
    • Agenda Setting - Rationale • S tructure a cros s a nd within s e s s ions • Fos te rs a colla bora tive a pproa ch • Importa nt topics a re cove re d • Effe ctive work in the time a va ila ble • Fos te rs a proble m s olving a pproa ch • Good wa y of monitoring progre s s • S e cure s tructure to he lp the m ma na ge the s e s s ion • The y ca n think a bout it be fore ha nd a nd bring pre pa re d a ge nda ite ms
    • Feedback - Rationale • To de te rmine the pa tie nts unde rs ta nding of a nd re s pons e to the s e s s ion • To ide ntify dis tre s s ing cognitions tha t ma y not othe rwis e be re ve a le d • Fa ilure to do this ma y le a ve with mis unde rs ta nding or ne ga tive inte rpre ta tions • Encoura ge s pa tie nts to ‘che ck out’ pe rce ptions • Fos te rs ope nne s s a nd colla bora tion • Give s re a l life e xa mple s of how pa tie nt proce s s e s informa tion , e .g . inte rpre ta tions of comme nts • P rovide s a focus on wha t pa tie nt ha s found he lpful
    • Homework - Rationale • Home work a s s ignme nt is a colla bora tive e nte rpris e • Cre a te s a link be twe e n s e s s ions - pa tie nt continue s to work on proble ms • Colle ction of da ta to a dd to e xplora tion • Ena ble s te s ting out of pre dictions • Ena ble s e xpe rime nta tion • Empha s is e s pa tie nts involve me nt in the cha nge proce s s • Encoura ge s s e lf monitoring , s e lf e va lua tion a nd s e lf re inforce me nt • Fa cilita te s progre s s ion through the le a rning cycle
    • Examples of Socratic Questions • Ha ve you be e n in s imila r circums ta nce s be fore ? • Wha t he lpe d in the pa s t? • Wha t do you know now tha t you did not know the n ? • Wha t would you s a y to a frie nd in tha t s itua tion ? • Wha t we nt through your mind the n ? • Wha t doe s tha t me a n a bout you ? • Do you know a nyone e ls e who ’s ha d tha t e xpe rie nce ? How did the y de a l with it? • Ha ve you a lwa ys he ld this be lie f? • Wha t wa s diffe re nt the n ? • The re a re thous a nds more
    • Challenging Distressing Thoughts  Identify the most distressing thought  Asking a series of questions designed to help person think about an alternative perspective  If someone that loved you knew you were thinking this what would they say to you ?  If someone that you loved was thinking this way what would you say to them ?  When you are not feeling like this do you think about this any differently ?  What is the worst/best and most likely outcome ? What could I do to cope ?
    • Imagery Modification • Ide ntify the ima ge , e motion a nd a ny AT • S pe nd time on de s cribing the ima ge • De te rmine re s pons e to ima ge • Cha nging conte nt, re s pons e or thoughts a bout ima ge
    • Components of Cognitive Therapy Collaborative Agenda Present Driven Oriented Feedback Guided Homework Discovery Goal Oriented Evidence Formulation Based Driven
    • Brewin and Watson (1998) • N=740 various cancer sites • 23% intrusive memories • Minutes, at least once per week, mostly vivid, physical sensations and reliving • 59% illness, injury or death of a relative or friend (46% cancer) • Some own cancer
    • Conclusions of Brewin and Watson (1998) study • Highly intrusive autobiographical memories re specific illness or death related events • Strong relationship to being depressed • Onset or exacerbation of intrusions associated with onset of depression • More overgeneral memory recall • Linked with greater avoidant thinking
    • Stanton et al. (2002) Journal of Clinical Oncology, 20(20), 4160-4168 Randomised trial - stage I or II breast cancer Within 20 weeks of completion of Rx (1) deepest thoughts & feelings (EMO) (2) positive thoughts & feelings (POS) (3) facts of experience (CTL) Psych & physical morbidity at 1 & 3m
    • Stanton et al. (2002) Journal of Clinical Oncology, 20(20), 4160-4168 • EMO and POS had less appointments for cancer related morbidity • 1-3 less visits than the control condition • Less self reported physical symptoms • 4-23 less days on which symptoms are experienced
    • Why ? • Vehicle for clarifying and pursuing goals • More discriminating re use of appointments • Distress previously expressed somatically may have been channelled into writing
    • Implications of Stanton et al (2002) • Expressive disclosure more beneficial (less distress) for those low on cancer related avoidance • More avoidant women more benefit from the work on benefit finding • Limited by self report nature • Need to examine with other stages and less motivated patients
    • Facilitating Emotional Expression: Indications (Moorey and Greer, 2002) • Re ce nt ons e t in conte xt of s pe cific cha nge • Ma rke dly fluctua ting e motions • S a dne s s a nd fe a r (not de pre s s ion a nd a nxie ty) • Appropria te but ne ga tive thoughts • Be lie fs a bout ne ga tive impa ct of e motions
    • ‘Realistic’ Automatic Thoughts • P e rs ona l me a ning • Cha lle nge unde rlying bia s • P roble m s olving • Appropria te e motiona l e xpre s s ion • Exa mine us e fulne s s of thoughts • Activity s che duling to e nha nce control • P la nning for the future • S che dule worry/grie f pe riods
    • Modifications of CBT in advanced or terminal illness • S e s s ions le s s forma l, more fle xible a nd more s upportive • S e s s ions ma y be brie fe r a nd a djus te d to pa tie nts phys ica l s ta tus • Te chnique s a re a djus te d to pa tie nts phys ica l s ta tus • The ra py include s fa mily a nd he a lth profe s s iona ls • Goa ls of the ra py a re more circums cribe d • P rima ry goa l of the ra py is to promote ma ximum cha nge with minimum inte rve ntion
    • Clinical Applications and Obstacles • Mos t of my work now is focus e d a round a s s e s s me nt, conce ptua lis a tion a nd ca s e ma na ge me nt a dvice – Applica tion of s pe cific a s s e s s me nts (e .g . Thought Control Que s tionna ire ) • La ck of s ha re d knowle dge ba s e a nd diffe re nt ‘culture ’ (ofte n the focus of a s s e s s ing s ta ff be lie fs e .g . ‘If you focus on dis cus s ing tha t the n s he will los e a ll hope ’)
    • Integrate CT with your practice … • Symptom Monitoring • Homework • Tailoring Specific Questions • Setting up a behavioural experiment • Graded Exposure • Referral for CT – assessment and case management recommendations