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An electronic circular of the Coalition's Center for Rehabilitation and Recovery
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No. 97, October 2013
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The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects. Cognitive Therapy for Beginners and Thieves: An Interview with Judith Beck, PhD Clinicians of different stripes adopt ideas from cognitive therapy with varying levels of expertise, perhaps reflecting Picasso’s belief that, “Good artists copy, great artists steal.” But what motivates therapists to covet concepts from cognitive therapy in the first place? To find out, RECOVERe-works editor Elizabeth Saenger, PhD, interviewed a foremost practitioner of the art and science, Judith S. Beck, PhD, President, Beck Institute for Cognitive Behavior Therapy; Clinical Associate Professor of Psychology in Psychiatry, University of Pennsylvania. Question: What are the goals of cognitive therapy? Cognitive therapy, also termed cognitive behavior therapy (CBT), aims to help clients achieve a remission of their disorder as quickly as possible, and to reduce the likelihood of future relapse. Question: How does it differ from other talk therapies used today? CBT is time-sensitive, structured, goal-oriented, and problem-solving focused. About half of what we do is to help clients solve their real life current problems. The other half is teaching them skills to change their unhelpful thinking, behavior, and emotional responses. Treatment is highly collaborative. Clients and therapists act as a team to decide what to address in treatment, to solve problems, to determine what the client does between sessions to follow up what they learned in session. We put a big premium on relapse prevention, telling clients that our goal is to help them learn skills so they can become their own therapist. Question: What is the theory that CBT is based on? CBT is based on the cognitive model, which posits that situations don’t directly affect how we react (behaviorally and emotionally), it’s our thinking that influences our response. For example, if I’m depressed and my friend doesn’t call me back, it isn’t the absence of a return call that makes me feel sad. I feel sad because I thought, “She must not care about me anymore.” When people are in psychological distress, they often are not thinking clearly. One important aspect of CBT is to teach clients to identify their dysfunctional thinking and evaluate it. When they assess a situation more realistically, they feel better and can behave more adaptively. Question: What is a typical session like? A typical session has three parts. At the beginning, the therapist does a “mood check” with clients, sets the agenda (by asking clients to name the problems they want help in solving that session), creates a bridge from the previous session to the current one, and reviews the action plan (the individualized assignments the client agreed to do at home). In the second part of the session, therapists collect data about the most important problem, conceptualize it according to the cognitive model, and check out the conceptualization with the client. Then together, they may work at the situation level, doing problem-solving; at the thought level, evaluating and modifying the client’s thoughts or underlying beliefs; at the emotional level, teaching the client emotional regulation techniques; and/or at the behavioral level, teaching the client new behavioral skills. Therapists ask the client to then summarize what they believe is important for them to remember and to do in the coming week and this summary and “action plan” is recorded so the client can read (or listen to) it daily. At the end of the session, therapists check to make sure the clients’ action plan feels doable and elicits feedback: What did the client think about the session? Was there anything he/she felt the therapist didn’t understand? Anything he/she wants to do differently next session? Flexibly following a structure like this is the most efficient way of getting the work done in session. It insures that clients have the opportunity to think through what is most important to them to discuss in session, and to leave the session with a specific plan that will help them solve their problems, and feel better. How do you deal with a client's resistance in treatment? Clients’ resistance makes sense once we understand their beliefs and their characteristic ways of dealing with the world. We expect that many clients will be resistant and that it is our responsibility to conceptualize the resistance and motivate the client to engage in treatment. The way that clients view themselves, their worlds, and other people outside of the therapy session is reflected in the therapy session itself. So, for example, if a client believes that she is vulnerable and that other people are likely to hurt her, she will likely believe that her therapist will hurt her if she opens up. In session, we see her act in a guarded way, often saying, “I don’t know,” changing the subject when the therapist probes too deeply, and so on. One important technique we would use would be to elicit her mood and thinking when we see one of these therapy-interfering behaviors. When she is reluctant to answer a question, we might say, “That’s fine. You don’t have to tell me. But how did you feel when I asked that question? What are you concerned might happen if you did give me an answer?” How effective is cognitive therapy? Cognitive therapy has been shown to be effective in over 1,000 outcome studies, for a range of psychiatric disorders, psychological problems, and medical conditions with psychological components. How commonly is cognitive therapy used? Why? Many practitioners these days use some cognitive techniques in their work, but do not demonstrate competence in delivering CBT treatment. The greatest problem is that graduate students are exposed to CBT but are not thoroughly trained. Even if they cover CBT in their course work, nearly all of their supervised practice is from non-CBT therapists. This is surprising, and disheartening, especially given the efficacy of CBT, as demonstrated over and over and over again by researchers throughout the world. What can different stakeholders in behavioral health, for example, clients, clinicians, administrators, policy makers, and the public, do to increase the chances that this evidence-based treatment is used appropriately? Therapists need to be well-trained. Research has shown that attending workshops or training sessions alone does not generally lead to short-term competence, much less long-term competence. When we work with individual therapists, we supplement workshops with a robust supervision program. When we work with organizations, we work hard to get buy-in from everyone, from bottom to top. We may train an entire staff or we may train key people, bring them up to competence, then teach them to train others. We use a standardized, validated assessment tool to measure competency so we can make sure therapists are delivering effective care. Five Tips to Help You Give Your Clients the Most in CBT 1, Toward the beginning of therapy sessions, ask clients to name the problem or problems they most want help in solving, so you can collaboratively decide how to spend your time together. 2. Ask for feedback at the end of sessions so you can uncover any problems clients have with you or with the process of therapy. 3. Make sure treatment is collaborative. Provide rationales for interventions and seek clients’ approval for using these techniques. 4. Teach clients specific skills to think more realistically, behave more adaptively, and regulate their emotions more effectively. Ask them to practice their skills between sessions. 5. Throughout the session, consider how you can help clients feel better by the end of the session and have a better week. Current Cognitive Behavior Therapy Resources Up-to-the minute resources on CBT include:
Seven Common Questions about Cognitive Remediation Alice Medalia, PhD Cognitive Remediation (CR) is one of the skills training interventions that can be provided within a psychiatric rehabilitation program. CR focuses on neuro-cognitive (for example, attention, memory) and social-cognitive (for example, emotion perception, theory of mind) skills to improve the success and satisfaction people experience in their chosen living, learning, working, and social environments. Like any psychiatric rehabilitation intervention, CR is a collaborative process that is person-centered and recovery-oriented. The ultimate goal is to help clients develop the cognitive skills and/or supports needed to achieve their goals. It is not difficult to set up a CR program, and the rewards will become quickly evident in client satisfaction, and progress toward recovery goals. There are a number of published and web-based resources about CR program development, as well as CR experts who can serve as guides throughout the process. Below are answers to some questions that are commonly asked by people who want to start a CR program. 1. What does a CR session look like? When conducted in a psychiatric rehabilitation setting, CR is provided in groups of six to eight clients that meet at least twice weekly, with sessions ranging from 45-90 minutes long. In each CR session, the bulk of the time involves individualized computer-based cognitive activities. There is also a 10-15 minute verbal discussion about the use of cognitive skills and strategies in real world situations. Because the treatment is personalized, each person works at their own pace on computer tasks chosen to address their particular needs. The clinician provides individual guidance and support, and facilitates the group discussion. 2. How does one start a CR group? Establishing a CR program can take several months. A typical time frame is: 2 months to purchase computers and supplies, designate a clinician, and set up a space; 2 months to train the staff; and 3 months to build up to a caseload of 12 clients. Because CR clients work at their own rate, there is a rolling admission to the groups. Should one client then leave, another one is recruited to fill the spot. This way groups are comprised of clients in different stages of treatment, which can enrich the potential for productive interactions and peer mentorship among group members. 3. What does it cost to start and run a CR program? Costs relate to the physical space, staff, and computer related equipment and supplies. There needs to be at least one designated CR clinician; a commitment of 5 hours per week allows for 3 hours of group time and 2 hours assessment and administration for a case load of 12, assuming 6 clients are seen at a time. The physical space needs to accommodate at least 6 computers and allow space for group discussion. There needs to be one internet enabled computer, one set of headphones per client, and one printer networked to all the computers. Cognitive training exercises need to be purchased, either as software discs, or contracts with web delivered programs. In 2013, software discs typically cost $2500, while annual cost for unlimited use of a web enabled package of 28 exercises for 10 users was $600. 4. What is involved in the Referral and Assessment process? Referrals are a collaborative process between the care coordinator, client and CR clinicians. Scheduling a 45-minute in-service on cognition in the psychiatric disorders is an excellent way to train staff (and clients) to recognize who might benefit from CR. The CR clinician facilitates the process of referral, assessment, and enrollment, and maintains the recovery orientation of CR by linking CR to each client’s goals. A clinician will need to be trained to administer, score, and interpret the results of a brief 20-30 minute cognitive assessment and then create a CR treatment plan that is linked to other psychosocial interventions and the overall recovery goal(s). 5. How does one choose the Cognitive Training Exercises? Training exercises used in CR provide computer-based drill and practice exercises, paper and pencil tasks, strategy coaching, and/or teaching of compensatory skills. There is a wide array of computer-based exercises to choose from, and most provide 30-day free trials. Manuals (many at no charge) are available for some CR approaches. 6. Who should be the Cognitive Remediation Therapist? No schools formally teach people how to do cognitive remediation with psychiatric patients, and there is no one group of clinicians who is trained in this specialty. CR is a skill that is now taught in workshops, or by a supervisor, and is ultimately developed within the practicum context. In general, clinicians who will be expected to run the program should have at least a Master’s degree in a mental health field. 7. Where can I get more information about setting up a CR program: The Alliance for the Study of Cognitive Disorders can provide information about people in your area who offer training and more information about CR. The contact person is Paul Johannet, at [email protected]. Dr. Medalia is Professor of Clinical Psychiatry, and Director of Psychiatric Rehabilitation Services, at the Department of Psychiatry, Columbia University College of Physicians & Surgeons. She can be reached at [email protected]. Thomas Blackburn I’m the 62-year-oldest of four, living with bipolar disorder since college…a one-time urban planner turned peer counselor. One sister is a dysthymia-plagued social worker, the other started as a corporate lawyer, but a brain injury induced bipolar tendencies and long unemployment. She’s now a librarian. My brother, who has put up with OCD since childhood, hasn’t worked in years, although he played the stock market successfully for a while. We’re a family of unfulfilled ambition often looking for someone among us (including parents) to blame. Our 87 year-old mother is too frail to be the sounding board anymore for our recriminations. After years of dealing with this turmoil by trying to tune it out, I have taken a new tact—using the non-judgmental, deep listening of one peer to another. While I still get angry at my siblings, now I use this empathy, like centering in meditation, to allow them to express themselves calmly. It’s good for them and for me, although, at this point, we can only slightly bend the course of our history. Stressing the Subjective in Cultural Competence Steven Anderson Despite the best efforts of researchers and clinicians, disparities in mental health care persist. The 2012 National Healthcare Disparities Report,[1] published yearly by the U.S. Department of Health and Human Services, concludes that although the overall quality of healthcare has improved in the US, racial and ethnic minority and low-income individuals still encounter more barriers to care and receive poorer quality of care. To address these disparities, researchers and clinicians have stressed the need for culturally competent theory and practice.[2] A widely adopted definition of cultural competence describes it as “set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations.” Although the term “cultural competence” may seem intuitively understandable, it has suffered from a lack of conceptual clarity and difficulty in measuring.[3] One organization within New York City that aims to reduce health care disparities is The New York Coalition for Asian American Mental Health (NYCAAMH), founded in 1989. On October 10, the Coalition held its annual conference, “Contemporary Clinical Practice with Asian American Clients: A Relational Perspective.” In the keynote presentation, Irene Chung, PhD, LCSW, argued that culturally informed clinical practice (or cultural competence) is best achieved by including considerations of culture into every stage of theory development. A relational approach, which prioritizes the therapeutic alliance and understanding the subjective experience of the client, was provided as an example of a framework that may enable more sensitive cultural considerations in clinical practice. From the relational perspective, a seemingly counter-intuitive finding emerges: Clinicians should resist over-emphasizing their client’s cultural background, or assuming that they can’t help a client simply because they are from a culturally divergent background. Clinicians should of course acknowledge and be aware of their clients’ linguistic and sociocultural details, including the degree to which a client’s culture or language ability may be related to reported functional impairments. But first and foremost clinicians must understand their client’s unique and individual subjective experience. This subjective experience may certainly be informed by the client’s cultural background, but it is nonetheless more important to consider than what box a client checks off on a questionnaire. Steven Anderson lives and works in New York City as a clinical research coordinator. References
How Can Providers Make Families Their Best Ally in Recovery? One Family Member’s Perspective Judith Carrington Providers often view families as invasive, hysterical and another difficulty of an already difficult job…and they are often quite justified in their perception. Under stress conditions, families plunged into a crisis voyage with no compass or knowledge of a very tough sea, reeling, seasick and lost, can be a volatile group. I was one of those “cases.” Reflecting back, it’s not hard to see that in my complete denial, my behavior toward providers was demanding and not altogether rational. My daughter had several hospitalizations, but with help along the way from mental health providers, she has built an independent life allowing us to have a wonderful relationship. Other success factors include a considerable amount of psychoeducation, brainstorming with other families struggling to navigate their own emotions and the complicated mental health system, and a decision not to be overwhelmed, but to put myself first. I’ve often wished to share with providers some of what I learned that could, from the outset, help make other families constructive instead of obstructive, see providers as “us” instead of “them,” and understand that it’s not providers’ fault that crisis often forces them to be the “bearers of bad news.” The following suggestions are a “to do” list for providers working with family members experiencing strong emotions:
It’s taken me almost ten years to understand, accept, and be comfortable about the new life my daughter’s struggles have brought us. I see that as both of us self-educated, we worked better with providers to gain the benefits and services to build the life we so dearly need. Once I realized I could contribute to my daughter’s recovery, I stopped waiting for a miracle from the system and I joined the challenge to work with the system. Judith Carrington, founder of Mental Health Resources, can be reached at [email protected]. Resources for Families
The Latest Research: Why We Got It Wrong with Stigma Elizabeth Saenger, PhD Prejudice against people with mental illness has been a longstanding problem in this country. As an April 2013 poll by the Kaiser Family Foundation[1] shows, Americans report they would be somewhat or very uncomfortable working in the same place as someone with a serious mental illness (41%), or having their children attend a school where someone with a mental illness is employed (66%). For years, advocacy groups have tried to reduce stigma against people with a psychiatric diagnosis by focusing on biological and genetic origins of mental illness. Whether they were proclaiming the decade of the brain, or drawing parallels between behavioral and physical disorders, the message was the same: mental illnesses are biological disturbances, and they are inherited. Lumping all mental illnesses together, however, ignores research indicating that people stigmatize those with different conditions in different ways. For example, research[2] shows that individuals who accept genetic explanations for problems in behavioral health tend to fear unpredictable violence by those with schizophrenia, and feel this threat cannot be reduced because it is innate. At the same time, their acceptance of genetic explanations causes these individuals to reject the common misconception that someone with depression is lazy, so they are less likely to display prejudice toward a person with depression. Consequently, anti-stigma campaigns focusing on biological and genetic (vs psychological and environmental) origins for mental illness may exacerbate stigma depending on the diagnosis under consideration. A recent article by the Canadian Health Services Research Foundation[3] reviews the irony that good intentions have wrought, and suggests that to reduce stigma, campaigns emphasize the solid research on the role psychological and environmental variables play in mental illness. This would bring anti-stigma efforts more in line with the evidence, and reduce the “us vs. them” dichotomy that arises when groups perceive that membership in their group, or a contrasting group, is permanent. Such an orientation for long-term efforts to reduce stigma is on-target, and critical to reducing stigma. References
Noted with Pleasure We are delighted to announce the upcoming publication of a book on the pioneering approach one of our member agencies uses to facilitate recovery through community. Fountain House: Creating Community in Mental Health Practice, due to be released next month by Columbia University Press, shows how the application of several core principles, such as professional/peer collaboration, led to evidence-based innovation whose success, as measured through employment, housing, education, and health, changed standard rehabilitative practices and inspired the creation of other clubhouses. Our next issue will feature an interview with co-author Kenneth Dudek, president and executive director of Fountain House, and include tips that agencies can use to foster social inclusion, recovery, and personal empowerment. Stay tuned! Beyond Light Therapy for Seasonal Affective Disorders Often, social work psychotherapists in private practice need other practitioners to whom they can refer clients, and vice versa. To fulfill these complementary needs, the Private Practitioners Group of the New York City Chapter National Association of Social Workers is hosting an event for varied professionals. Date: Monday, November 11, 2013 (Veteran's Day) Location: NASW chapter office in the Financial District in lower Manhattan Speaker: Michael Terman PhD, a leading researcher, psychologist, and clinician at Columbia Agenda: 6:30 – 8:00 Presentation on Chronotherapy (“bright light therapy” for seasonal affective disorder (SAD) and other evidence-based treatments for a variety of disorders). There will be networking for an hour before, and an hour after, the program. Cost: $15, free to NASW members Questions? Contact Lynne Spevack, LCSW, ([email protected] and 718-377-3400).
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