discussion #6 disease

+

Cognitive Behavior Therapy (CBT) for Medical Problems Overview of Treatment Strategies

+ Chronic Illness

n  Patients experiencing a chronic medical condition can face a high degree of uncertainty.

n  Psychological adjustment can be impacted a result of declines in physical health.

n  Chronic medical conditions often require increased self-care demands that may or may not be within the patient’s control.

n  Patients with a history of psychological problems can be more vulnerable to experiencing symptoms during the course of their chronic illness.

n  For some patients, the medical problem itself confers a psychological vulnerability to experience problems triggered by other life events.

+ Meaning – Based Interventions

n  Patients tend to attach ‘special meanings’ to life events associated with the chronic illness.

n  Therapists need to understand the framework from which patients derive meaning for their experiences and devise interventions accordingly.

n  The way in which meanings are processed can be as important as the meaning content.

n  CBT’s focus on meanings and interpretation makes it a suitable alternative for addressing the psychological components of chronic medical problems.

+ CBT Overview

n  CBT can be applied to the assessment and treatment of almost any chronic medical problem.

n  CBT has been proven to be effective for the psychological problems that are often associated with chronic illness (e.g., pain, fatigue).

n  CBT and medical self-management can go hand-in-hand because of their emphasis on skill-building and the collaborative nature of the provider-patient relationshi.p

n  CBT is a structured form of therapy that differs from unstructured and non-directive counseling interventions and support.

+ CBT Overview (Continued)

n  CBT is the most often used most effective psychotherapeutic intervention for chronic medical conditions.

n  CBT can be helpful in resolving challenges such as: n  Non-compliance n  Illness Denial n  Symptom Exacerbation n  Spiritual and Life-meaning Issues

n  Numerous randomized controlled trials (RCTs) provide evidence of CBT’s effectiveness in increased psychological and physical well-being.

+ CBT for Medical Problems

n  CBT is easily accepted by patients with chronic medical conditions for several reasons: n  The approach is direct and it focuses on the here and now.

n  It is appealing to patients because it is neither mysterious nor too removed from their experience. It analyses only the material (thoughts and interpretations) that the patient is willing to share in a systematic and detailed fashion.

n  It increases the patient’s understanding of their chronic medical condition and promotes specific behavior changes that the patient (not the therapist) proposes and plans.

n  It motivates and promotes behavior change by having patients analyze their own thoughts and behaviors.

+ CBASP

n  CBASP stands for Cognitive Behavioral Analysis System of Psychotherapy.

n  It was developed for the treatment of chronic depression and has been adapted for use with medical illness.

n  Unique to this approach is an inquiry about behaviors and interpretations or beliefs that result in unwanted outcomes or consequences compared with alternative behaviors and beliefs that can result in desired outcomes or consequences.

n  CBASP provides a ‘cognitive map’ for therapeutic processing of a situation.

+ CBASP (Continued)

n  The adapted form consists of nine steps formulated as clinician-initiated inquiries (Sperry, 2005).

n  Steps: n  1. Can you describe what happened? Elicit situation narrative with beginning,

middle, and end.

n  2. What was your interpretation of your thoughts about the situation?

n  3. What were your behaviors? What did you say, what did you do? What were your feelings?

n  4. What did you want to happened? What did you desire or expect would happen?

n  5. What actually happened?

n  6. Did your behaviors and thoughts promote your health and well-being or detract from it?

n  7. Can we analyze this together to see what happened and what might be different?

n  8. Taking each specific thought and behavior: did this thought or behavior help or hurt you in terms of getting what you wanted?

n  9. What alternative thought or behavior might have better helped you get what you wanted? Specifically, how would this new thought or behavior get you what you wanted?

+ Illness Acceptance Interventions

n  Illness denial is an individual’s unwillingness to acknowledge and accept that they have a chronic disease and the impact that disease state has on them

n  It is a major cause of treatment non-compliance or nonadherence

n  Illness acceptance is associated with positive treatment outcomes

n  CBT interventions can engender the shift from illness denial to illness acceptance

+ Illness Acceptance Interventions (Continued) n  CBT interventions that promote illness acceptance focus on issues involving

illness perceptions, relationship issues, or grief issues. This can be done separately or on two or more of these issues together.

n  The goal is to modify illness perceptions, particularly those that are distorted or inaccurate and thus associated with illness denial.

n  Interventions seek to have the patient associate their medical condition with more positive illness perceptions and greater levels of self-efficacy with regards to self-management.

n  Interventions focusing on relationship issues can take place when the patient’s significant other(s) do not accept the patient’s medical condition and expect that life can somehow remain the same. Conflict usually arises when the patient attempts to meet this expectation by being ‘the same person’ they were before their illness diagnosis and is not able to.

n  Interventions can also help patients grieve the loss of their pre-illness sense of self and lifestyle activity level.

+ Treatment Compliance Interventions n  Compliance or adherence is defined as the extent to which a person’s

behavior coincides with medical advice.

n  Treatment noncompliance is one of the most complex challenges facing health care providers working with chronically ill patients.

n  It is believed that the patient’s family is key in fostering adherence. Family members can can make the difference between compliance and and improved health outcomes or noncompliance and reduced health outcomes.

n  Family dynamics can impact a patient’s compliance with a treatment regimen for both medical conditions and lifestyle change.

n  Derived from the cognitive behavior analysis system of psychotherapy, the 9 step therapeutic interviewing strategy can lead to increased compliance by involving the ‘therapeutic triangle’ of the patient, healthcare provider, and the family.

+ Symptom Reduction Interventions

n  CBT interventions can target medical symptom reduction.

n  These strategies can help individuals cope with symptoms by reexamining their health beliefs and expectations as well as exploring the impact of assuming the sick role and stressors on their symptoms.

n  CBT is effective in reducing symptomatic distress because focused strategies can provide alternative explanations for symptoms, restructure faulty beliefs about the disease process, modify treatment expectations, and offer effective coping techniques (e.g., distractions and focused attention).

n  CBT strategies stimulate individuals to assume an active role in the treatment process, as opposed to other passive strategies such as medical and technological interventions (i.e., TENS units for pain management).

+ Life Meaning Interventions

n  Life meaning issues tend to be prominent for individuals experiencing chronic medical conditions.

n  Awareness of a patient’s religious or spiritual beliefs allows therapists to understand how a patient copes with their chronic illness experience.

n  Helpful or positive religious/spiritual coping strategies include perception of spiritual support and guidance, congregational support, and attributions of negative life events as the will of God.

n  A modified cognitive behavioral analysis model can be useful and valuable in clarifying these issues and increasing coping capacity.