day 2 PDF handout - Serenity Programme

Transcription

Serenity Programme - serene.me.uk
02/02/2014
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SERENITY
PROGRAMME
TRAINING
Helper Training
Day two – updated 02-02-14
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Contacts
Contents
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The ‘4P’ model (Patient, Provider, Program, Problem)
Communication types
The relationship
Cues and dynamics
John Suler – 6 characteristics
Intervention priority sequencing
Single-session therapy
NICE guidance and CCBT
SERENE.ME.UK/HELPERS/
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Welcome!
What would you have to do, or
what would have to happen here
today for you to be able to say:
THE ‘4P’ MODEL
‘That was time well spent!’
Steve Cottrell
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The ‘4P’ Model
The ‘Patient’
• NICE recommends that anyone meeting the criteria for
Program
Patient
– GAD
– Panic Disorder
– Persistent Sub-threshold Depression
– Mild to Moderate Depression
Provider
Should be offered the choice of CCBT
Problem
• There is little formal evidence that younger people in
general are more suited to CCBT …
Cavanagh, K. (2010) Turning on, tuning in and (not) dropping out. In J. Bennett-Levy (Ed). Oxford Guide to Low Intensity CBT
Interventions. Oxford University Press: Oxford, UK.
Cavanagh, K. (2010) Turning on, tuning in and (not) dropping out. In J. Bennett-Levy (Ed). Oxford Guide to Low Intensity CBT
Interventions. Oxford University Press: Oxford, UK.
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Generations
Generation
The ‘Patient’
Birth Date
Age at 2013
Generation ‘Z’
After 1994
19 or less
Generation ‘Y’
1977 - 1993
20 - 36
Generation ‘X’
1965 - 1976
37 - 48
Younger Boomers
1955 - 1964
49 - 58
Older Boomers
1946 - 1954
59 - 67
How do they tend to spend their time online?
What are their values and concerns?
What is their relationship with technology?
What experiences helped shape their relationship with
technology?
• What do they like and dislike?
• What could we, as helpers, usefully bear in mind about
different generations?
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Generations
Baby Boomers
Silent Generation
1937 - 1945
68 - 76
G I Generation
Before 1936
77 +
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Age (Years)
49 - 67
Generation ‘X’
37 - 48
Generation ‘Y’
20 - 36
Generation ‘Z’
Less than 19
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Who does What?
http://www.statista.com/topics/840/smartphones/chart/1489/the-generational-divide-in-cell-phone-use/
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‘Boomers’(49 - 67 years)
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Generation ‘X’ (37 - 48 years)
80% are online, 30% own smartphones
60% lost assets in economic downturn
The last generation to own a home on a single wage?
42% are delaying retirement, 25% say they'll never retire
Witnessed the birth of the home PC
‘Loyal workaholics’
Relatively high disposable income
Some ‘GUAVA’ - ‘Grown Up And Very Affluent’
Appreciate ‘lifestyle tech’
Appreciate 1:1 paradigm – e.g. Skype
Govt, health and financial info: ‘Trusted sites’
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‘A worldview based on change’ (Christine Henseler, 2012)
Relatively high educational attainment
‘Manufacturing’ to ‘service’ economic change
Witnessed the birth of the Internet
Teens / young adults during Thatcher era (1979 – 1990)
First ‘latch-key’ generation (working mothers)
Independent, resourceful & self-sufficient
Parental divorce & redundancy
Grown with computers
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Generation ‘Y’ (20 - 36 years)
Generation ‘Z’ (19 years or less)
The ‘Millennials’
97% have a computer
Technologically sophisticated
Witnessed the birth of social media and Internet icons –
Facebook, Twitter, LinkedIn, MySpace, YouTube, Google
• Remember the ‘dot com bubble’ 1997 - 2000
• Dual income / single parent households
• Decline of faith & religion
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Technologically agnostic
The rise of the ‘smartphone’
Always ‘connected’, always ‘on’
Relatively low attention span
Facebook, twitter and texting
Private / public blurring
Accessibility of FE options?
Employment opportunities?
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Trends in Internet Usage
• The fastest growth in social networking is in people 74 and
older, rising from 4% to 16% between 2008-2010
• Searching for health information is the third most popular
online activity of users aged 18 and over
• Blogging is reducing in popularity with younger people,
being replaced by ‘micro-blogging’ (Facebook & Twitter)
• 81% of adults reporting no chronic disease go online
• 62% of adults living with one or more chronic disease go
online
• 52% of adults living with two or more chronic diseases go
online
• These trends apply when increasing age is controlled for
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The Patient
• Pre-treatment expectations predict treatment completion
(Cavanagh et al, 2010) and longer term treatment outcomes
(Graaf et al, 2010)
• Higher levels of motivation, program credibility, anticipated
adherence, self-efficacy and a lower degree of hopelessness
are associated with benefits achieved with self-help
programs (MacLeod et al, 2009)
Pew Research Center's Internet & American Life Project, April 29-May 30, 2010 Tracking Survey
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Expectations
Attrition
People’s expectations of CCBT may differ from the reality:
‘I didn’t expect homework’
‘I suppose I thought it would be some sort of counselling’
‘I wasn’t sure about their [helper] role - I didn’t realise that
she was going to work through the book with me’
• ‘I don’t know how long the sessions were supposed to be’
• Meta-analysis of studies of CCBT for depression mean
attrition rate 32% (range 0-75% - Kaltenthaler et al, 2008)
• No significant difference in attrition between guided self
help and FTF therapies in head-to-head RCTs* (Cuijpers et
al, 2010)
• Managing expectations, program matching, planning
endings, reviewing progress and strategies for managing
difficulties with engagement may support completion
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Macdonald et al, 2007
* Randomised Control Trial
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The Problem
The Program
• Anxiety disorders (GAD, Panic Disorder, Phobias, PTSD,
Social Anxiety, OCD)
• Depression
• Others …
• The need for support can vary by disorder
• Software has ‘personality’ - users report a therapeutic
alliance with CCBT programs (Ormrod et al, 2010)
• People relate to both hardware and software
• Human-computer interaction and ergonomics
• Understanding of critical factors is in early stages
– Anxiety can often benefit from minimally guided self-help
– Depression may require additional support
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Newman et al (2011)
• Depression may be associated with reduced motivation,
reduced activation, feelings of hopelessness, rumination
and cognitive impairment which may make engagement
more difficult
Behavioural change
Interpersonal component
Options to personalise
Placebo / halo effect
Generalisation
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The Provider
The Provider
• Therapists with training in self-help are more confident and
positive about self help (Keeley et al, 2002)
• Therapist expectancies and frequency of programme use are
improve with training (McLeod et al, 2009)
• A clear deadline for the duration of the treatment improves
completion (Andersson et al, 2009)
• A scheduled 10 minute contact, no more than once a week
seems important - no added value to more frequent contact
(Klein et al, 2009)
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Force Field Analysis Worksheet
Driving Forces (+)
Force Field Analysis - Exercise
Restraining Forces (-)
• What driving forces are taking you forward with
computer-based approaches?
• What restraining forces (barriers) are holding you back
from using computer-based approaches in your work?
• Take your list of restraining forces and identify in the
box on the worksheet the actions you plan to take to
reduce these restraining forces
Actions to reduce the Restraining Forces
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COMMUNICATION
TYPES
Communication types
Synchronous communication
• Instant messaging e.g. Google Talk TM
• Telephone
• Virtual environments e.g. Second Life®
• Video and audio links e.g. Skype TM
Asynchronous communication
• Email
• Bulletin board
• SMS (text messaging)
Steve Cottrell
Benefits of asynchronous communication
• Fewer difficulties with managing an appointment time or
working across different time zones
• The convenience of replying when you're ready and able to
reply
• A ‘zone of reflection’ that allows helper & participant to
think. For the participant, this might bring opportunities for
issues concerning impulsivity, help develop a self-observing
ego & ‘working through’ of material. For the helper, replies
can be more carefully planned and countertransference
worked through more effectively
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Challenges with asynchronous
communication (1)
Challenges with asynchronous
communication (2)
• The boundaries of a specific, time-limited ‘appointment’ are
lost. Potential for the helper to feel overwhelmed by contact
from the participant, by receiving numerous, detailed or
frequent e-mails
• There may be a reduced feeling of ‘presence’ because the
participant and helper are not working together in the same
moment
• Some of the spontaneity of interacting ‘in the moment’ is
lost, along with what spontaneous actions can communicate
about a person
• There may be some loss of the sense of commitment that
meeting ‘in the moment’ can create
• Pauses in the conversation, arriving late and ‘no-shows’ are
lost as psychologically significant cues (although pacing and
length of replies in asynchronous communication may serve
as cues)
• The written word may be more ‘triggering’ than the spoken
word. What is written can be held and re-read as often as
the participant chooses, while it is easy to become
preoccupied with just one part of the message
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Challenges with synchronous
communication
Benefits of synchronous communication
• The ability to schedule sessions defined by a specific, limited
period of time & the boundaries implicit in an appointment
• A feeling of ‘presence’ created in real time
• Interactions may show more spontaneity, resulting in more
uncensored disclosures by the participant
• Making the effort to be with the person for a specific
appointment may be seen as a sign of commitment and
dedication
• Pauses in the conversation, coming late to a session and ‘noshows’ are not lost as temporal cues that may have
psychological meanings
• The difficulties and inconvenience in scheduling a session at
a particular time, especially if the participant and helper are
in different time zones
• There may be less ‘reflective space’ - the time between
exchanges to think and compose a considered response
• In the mind of the participant, ‘therapy’ may be associated
specifically with the appointment and not perceived as a
process that can occur outside of that time
(Adapted from http://users.rider.edu/~suler/psycyber/therapy.html accessed 01-12-12)
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Beginnings
The first stage in delivering a computer mediated approach is
information gathering. Some questions we may want to
consider are:
THE
RELATIONSHIP
Steve Cottrell
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What does the participant want?
In light of what the participant wants, can I / we help?
What are the risks of working with this participant?
Is this the most appropriate treatment for this person?
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The Contract
Clarifying the Boundaries
The contract defines at least two important aspect of the
relationship:
When and how will contact be made?
How many sessions will be provided?
For how long?
What access, if any, the participant has to the helper
between sessions?
• What are the limits of confidentiality?
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• The ‘business’ contract – defines the frequency of meetings,
duration, payment etc.
• The ‘therapy’ contract – helps define a focus and goals for
the intervention
• During initial contact, or early in the relationship, several
activities are often helpful …
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Clarifying the Purpose
Claude Steiner – 4 Requirements (1974)
1. Mutual consent - involves an offer and an acceptance
arrived at by negotiation
2. Consideration - includes the benefits conferred, which may
be bargained for and that are agreed upon. Each puts
something of value into the relationship
3. Competency - both parties will be competent to carry out
what has been agreed upon in the contract
4. Lawful intent – ‘the contract must not be in violation of the
law or against public policy or morals, nor should the
consideration be such nature’ Steiner (1974, p250)
• What does the participant want from therapy overall?
• How do the therapy goals relate to the participant’s life
goals?
• What do they want / not want to happen?
• What are the participant’s expectations of the process?
• What can the helper provide?
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Expectations
• What does the helper expect from the participant?
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Punctuality?
Clear goals?
Demonstrable commitment?
Work outside sessions?
What else?
Steve Cottrell
A Multiplicity of Relationships
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The working alliance
The transference relationship
The reparative, or ‘developmentally-needed’ relationship
The person-to-person relationship
The transpersonal relationship
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The Working Alliance (1 of 2)
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The Working Alliance (2 of 2)
• The working alliance is the fundamental bond between
helper and participant
• The alliance develops within the framework of a clear
business contract
• Helpers support the development of the alliance by using
active listening skills and by modelling a collaborative
relationship
Bordin (1979) proposes three essential aspects of the working
alliance
• The collaborative setting of goals
• The joint agreement on tasks
• The development of a human relationship or bond
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ZPD
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The Transference Relationship 1
• Working within each individual patient’s zone of proximal
development (Vygotsky, 1978) aids the establishment and
maintenance of the therapeutic alliance. The zone of
proximal development is the area of ability where the
participant cannot yet complete tasks unaided, yet is
capable of doing so with support
• Transference describes the ways in which, outside of
awareness, we transfer our thoughts, emotions and
impulses onto others. We may ascribe to the other person
motives , desires, thoughts or emotions which are our own,
though of which we are, at best, only dimly aware
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The Transference Relationship 2
Transference has been defined as:
• ‘The experience of feelings, attitudes, fantasies, and
defences towards a person in the present which are
inappropriate to the person and are a repetition, a
displacement of reactions originating in regard to significant
persons in early childhood’
Greenson (1965, p156)
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Transference – Types 1
• Transference can be ‘positive’ or ‘negative’, in that it can
facilitate or impede effective working. It can be ‘proactive’ –
directly from our own experience, or ‘reactive’ – in response
to the transference of another person
• A key task in working with the transferential relationship is
to help separate the ‘here and now’ reality from thoughts,
behaviours and emotions that are more relevant to past
relationships
• All relationships will be influenced by transference
phenomena, those of helpers and participants alike
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Transference – Types 2
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Transference - Clarkson
• The intensity of a participant’s transference reaction and
our transferential responses to participants are useful
guides as to whether we can form a helpful and effective
helping relationship
• In the presence of intense transference, longer term
psychological therapy may be required
1. Proactive transference: What the participant brings to the
relationship / the participant’s projections of past
experiences onto the helper
2. Proactive countertransference: What the helper brings to
the relationship / the helper’s transference towards the
participant
3. Reactive transference: What the participant reacts to
because of what the helper brings to the relationship
4. Reactive countertransference: What the helper reacts
because of what the participant brings to the relationship
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The Reparative Relationship
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The Reparative Relationship
The developmentally-needed or reparative relationship is
defined by Clarkson (1995, p108) as:
• ‘Intentional provision by the psychotherapist of a corrective,
reparative or replenishing relationship or action where
original parenting was deficient, abusive or over-protective’
• Clarkson identifies three classes of problem which may
result in developmental gaps:
Missing elements, which may be provided in the reparative
relationship, identified by Clarkson (1995, p235) as:
• Containment
• Witness
• Care
– Trauma (e.g. sexual abuse)
– Strain or repeated less severe traumas (e.g. neglect and
deprivation)
– Extra-familial limitations and catastrophes (e.g. genetic
conditions)
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The Person-to-Person Relationship
Miller (2000) writes:
• ‘We have a responsibility to be a complete, responsive,
caring ‘other’ for the patient, and to understand that the
patient will develop and mature not only from our skill as
helpers, but also from our humanity’
• We can see the developing capacity for authentic person-toperson relating as a desirable goal of psychological therapy
• Authenticity means being true to one's own personality,
spirit, or character (Miriam-Webster, 2012)
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• The person-to-person relationship tends to emerge and
deepen as therapeutic relationships progress and the
relative influence of the transference relationship
diminishes (McCormick, 2000)
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The Transpersonal Relationship 1
• The person-to-person relationship may be characterised by
increased self-disclosure on the part of the advisor (Gelso &
Carter, 1985)
• Clarkson notes that the transition from the reparative or
transferential relationship to the person-to-person
relationship can be difficult, and when it happens,
frequently heralds a significant change in the relationship
• To be available for the authentic person-to-person
relationship we must be in touch with, aware of, and
responsive to, our own needs as individuals
• Transpersonal psychology has its roots in the work of
Abraham Maslow (1969)
• Transpersonal psychology studies the transpersonal,
transcendent or spiritual aspects of the human experience.
Transpersonal experiences may be defined as:
• ‘Experiences in which the sense of identity or self extends
beyond the individual or personal to encompass wider
aspects of humankind, life, psyche or the cosmos’
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The Transpersonal Relationship 2
Clarkson (1995 p181) describes the transpersonal relationship
as:
• ‘The timeless facet of the psychotherapeutic relationship,
which is impossible to describe, but refers to the spiritual
dimension of the healing relationship’
• While not within the helper’s role to provide spiritual
guidance, though we must remember not to neglect
participant’s issues of connectedness with others and the
wider world. Issues of life, mortality and existence, morality,
agency and absurdity will concern us all at times, perhaps
most during times of loss or transition
CUES AND
DYNAMICS
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Non-Proximal Therapy
A Hierarchy of Cues
• Psychological therapy provided without being in the same
room as the participant (non-proximal therapy) brings
unique challenges
• The fewer the cues there are about the emotional state of
the participants, the more challenges there may be
• Generally, as perceptual cues become increasingly limited or
as the potential for immediacy reduces, the greater become
the ‘perceptual gaps’ that may be filled by projections,
assumptions and fantasies – helpful or otherwise
• The further down the list, the fewer cues exist to facilitate
understanding between participants and the more skills are
required to communicate effectively on an emotional level
Steve Cottrell
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Face-to-face interaction
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Holographic or virtual reality
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Video link
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Telephone
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Shared virtual environments
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Instant messaging
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Email
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Letter
More cues
Fewer cues
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Projection – ‘Filling In’ Perceptual Gaps
Transference to the Machine
Peter Gay (1988, p. 281) describes projection as:
• ‘The operation of expelling feelings or wishes the individual
finds wholly unacceptable - too shameful, too obscene, too
dangerous - by attributing them to another’
• When people have limited information about the other, the
scene can be set for misunderstandings borne of projection
– where psychological material of our own is attributed to
the other person. The potential for projection is increased
the less we know about the other, and the more we may
tend to objectify them and ‘fill in the gaps’ with our own
unconscious material
• Some people see computers as helpful, they may view their
smartphones, tablet computers or personal devices as
personal, important and intimately their own
• Others may see computers as frustrating objects, unreliable
and mysterious, waiting to thwart them and poised to crash
and lose their personal material, or be invaded by evil
viruses or spyware
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Four-cornered Contracts
• In any form of technology mediated
interaction, all participants will bring
their own ‘baggage’ into the
relationship, so the relationship is
between at least four parties – the
agency, the participant, the helper
and the technology that facilitates
(or impedes) communication
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Disintegration and Primitive Processes
A
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P
• The result of destructive transference relationships and
hostile projections can be disintegration, where aspects of
the participant’s psyche become fragmented and the
experience of the self and a coherent and cohesive whole is
damaged
• Non-proximal therapy does not suit everyone, and care
must be taken to ensure prompt action is taken to ‘step up’
the participant to other services should disintegration or
decompensation be evident
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• The anonymity and immediacy of the Internet, together
with the lack of recognition of the others as being rich and
complex individuals has brought about a number of welldocumented adverse events, for example the
encouragement of online suicide and the pathology of
‘thinspiration’ sites
• The occurrence of ‘flame wars’ exhibit primitive splitting
and denigration – what may be termed ‘the cruelty of
crowds’
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• Issues brought about by the discussion early trauma may
provoke disintegration or decompensation, while people
with ‘body’ issues may feel safer online, where they may
feel free from the pressure of being scrutinised
• The premature termination of treatment, brought about by
a participant’s sudden withdrawal from services may signify
some attempt on behalf of the participant to protect
themselves from some noxious stimulus
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Identity Issues
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Identity Issues
• It is not always possible to know for sure who is on the end
of a telephone or who is listening in, and it’s often harder
still to assure the identity of the author of an email
• It is relatively trivial for people to impersonate others in an
email exchange (‘spoofing’) and a serious breach of
confidentiality can ensue
• Some people choose to work with a false identity online,
and without face-to-face contact there is sometimes little
that can be done to completely assure the age, identity,
even gender of a participant
• Advisors may want to identify a ‘key word’ or phrase known
only to the participant and advisor which means the email
can be reliably authenticated as coming from the participant
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Bystander Apathy
Bystander Apathy
• ‘Bystander apathy’ is a term coined after the murder of Kitty
Genovese in New York in 1964
• Kitty Genovese was stabbed to death near her home in
Queens, New York. Genovese parked 100 feet from her
apartment's door, when was approached by Winston
Moseley who stabbed her twice in the back. She screamed:
"Oh my god he stabbed me! Help me!" she was heard by
several neighbours; Moseley stabbed her several more
times. While she lay dying, he sexually assaulted her
• Investigation revealed that about a dozen individuals nearby
had heard or seen at least some part of the attack
• Kitty’s death prompted research into ‘bystander apathy’ –
the idea that someone else will do something about a
situation, leading to abdication of personal responsibility
• Responsibility diffusion is a well-known aspect of online
group working, where one might be unsure of the identities,
whereabouts or even number of people in an online group,
it is easy to assume someone else will act appropriately
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William Melchert-Dinkel
William Melchert-Dinkel
• William Melchert-Dinkel, 49, of Faribault, USA was
convicted in 2011 of two counts of aiding suicide
• Melchert-Dinkel, an ex-nurse, searched online for depressed
people. He posed as a suicidal 20 year old female nurse,
feigned compassion and offered instructions on how they
could most effectively kill themselves
• He took part in online chats about suicide with 100 people,
entered into fake suicide pacts with about 10, five of whom
he believed killed themselves
• He told police he did it for the ‘thrill of the chase’
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Anonymity, Immediacy and Disclosure
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Anonymity, Immediacy and Disclosure
• There is a tendency for Internet and other reduced-cue
interactions to move quickly to intimate levels of disclosure
- more quickly than face-to-face interactions
• This may be facilitated by anonymity, by positive
transference and by the disinhibition afforded by the
wearing of the electronic equivalent of a mask
• One of the common consequences of a rapid move to
intimacy is shock and withdrawal after revealing too much
of ourselves online.
• It is not uncommon for people to abandon online therapy
after realising how quickly they have revealed their more
intimate selves to someone relatively unknown
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John Suler – ‘Six Characteristics’
• John Suler (2004) has written about six characteristics of the
Internet which can lead to change in behaviour:
1.
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6.
JOHN SULER: SIX
CHARACTERISTICS
You don’t know me
You can’t see me
See you later
It’s all in my head
It’s just a game
We’re all equal
http://users.rider.edu/~suler/psycyber/psycyber.html
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Dissociative Anonymity
Invisibility
• You don't know me …
• Dissociative anonymity – we become deindividuated, as
though wearing a mask. We can’t be seen, so we are less
concerned about how we may look to others. We might act
as though we have permission to say exactly how we feel,
irrespective of the consequences
• You can’t see me …
• Allows for misrepresentation of the self e.g. male posing as
female & vice versa
• Invisibility prevents reading of social cues; small changes in
facial expression, tone of voice etc.
• Even if one's identity is known and anonymity is removed
from the equation, the inability to physically see the person
on the other end causes one's inhibitions to be lowered.
One can't be physically seen on the Internet, so the need to
concern oneself with appearance and tone of voice is
dramatically lowered & sometimes absent
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Asynchronicity
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Solipsistic Introjection
• See you later …
• Asynchronicity – face-to-face we receive rapid feedback
about the effects our words are having
• Without visual cues and with the potential for delays
between exchanges, we lack the normal feedback loops
which govern the flow and content of our exchanges
• It's all in my head …
• Reading the words of others can create a surprisingly
intimate bond with another person, based on what they
choose to reveal to us, rather than the many other, possibly
contradictory, non-verbal data that would help contextualize
the communication. Reading another's message can ‘insert’
imagined images of what a person looks like or sounds like
into the mind. We may associate traits to a user according
to our own desires, needs, and wishes – traits that the real
person may or may not possess
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Dissociative Imagination
Neutralising Status
• It's just a game …
• When we write on our computer or interact with a
programme, we can react as though entering a different
world, one we can leave at the press of a button and which
all traces of what we have done can be erased without trace
• It is easy to trivialise our impact on others when they are
seen through a computer screen. They become ‘actors’
instead of people, which somehow diminishes our
responsibility towards them. It can seem as though we are
moving pieces on a board, playing a game rather than
relating in any real, everyday sense of the word
• We’re all equal …
• The words on an email or web comments may come from a
person aged 6, 16 or 60. We may have little idea of the
thought or emotions behind a sequence of words typed
onto a screen
• There is no online ‘government’ and limitless opportunity to
provoke authority figures and then watch at the impotent
rage we can so easily provoke in others. For some people,
known at ‘trolls’, such provocation has almost become a
‘sport’
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Telepresence
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Mirroring
• Telepresence - the experience of being fully present at a live
real-world location remote from one's own physical location
• Screen size and ‘immersive experience’
• We don’t see ourselves as operating a telephone …
• The more ‘invisible’ the technology, the more immersive the
experience
• Potential for remote emotional work?
Robonaut 2
Steve Cottrell
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02/02/2014
85
86
86
87
88
Mirroring
• Say ‘hello’ without raising the eyebrows
• Mirror postures
Intervention Priority Sequencing
Danger (some threat in the system)
Confusion (some loss of focus in the system)
Conflict (some split, polarisation or conflict in the system)
Deficit (some experience of need or deprivation or for
reparation)
• Development (some requirement to increase depth,
breadth or complexity)
• Work needs to be done usually in this order of clearance if it
is to be effective
•
•
•
•
INTERVENTION
PRIORITY
SEQUENCING
89
Danger
• The conscious or unconscious preoccupation of the system
is with survival issues. These will often make work with
other themes ineffective
• Issues concerning homicide, suicide, psychosis, risk to
others and ethical concerns almost always need to be dealt
with first
• People cannot engage in learning, developing or healing
effectively if they feel endangered at any level - and this
includes moral endangerment, as in collusion with crime,
deceit or abuse
Steve Cottrell
90
Confusion
• Transference, countertransference and projective
identification can become pervasive and crippling. A system
suffering from confusion has difficulty identifying priorities.
High focus is associated with high effectiveness
• When the helper is confused about goals, there is a general
sense of disorientation and lack of direction. The task is to
restrain premature action and to help clarify issues, roles
and relationships
• Engaging in conflict resolution when the system is unclear
about the nature, consequences and significance of conflict
is often a waste of time and effort
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92
Conflict
Deficit
• Once clarification has been achieved, it is more probable
that conflict resolution, mediation, integration or mutual
respect for difference can be accomplished
• Conflict issues tend to be characterised by splits, energetic
activity, categorically different positions, failure of
negotiation, unwillingness to compromise and some
combination of active acting out or passive aggressive
behaviour
• Issues to do with replenishment, knowledge or skills deficits
are most likely to be effective if the previous stages have
been cleared
• Priorities when meeting a deficit are first to establish what
people already have as resources, skills, training, and
options
• For a helper worried about whether the client complaining
of persecution was psychotically paranoid, a call to the GP
and the local race relations office was all that was needed to
confirm that there was vicious harassment on the client's
housing estate
– Working too hard with high blood pressure, while being
reluctant to sacrifice what is felt as the adrenaline rush of
work
– Knowing that exercise will help depression, yet feeling too low
to exercise
93
94
Development
Reflective
Competence
• Increasing complexity, effectiveness, capacity and the range
and flexibility of understandings, sensibilities & behaviour
• The phase of 'unconscious incompetence’ which Robinson
(1974) showed follows ‘unconscious competence’ can be
transformed if the helper involves him / herself in a cycle of
continuing education, questioning and research
• When helping is rushed or provided in response to endless
demands these aspects are ignored at risk to the joy,
curiosity and creativity which brought people to this work in
the first place. The care of the professional, whether novice
or veteran, should accompany this priority if the system is
not to become an empty hypocrisy
Unconscious
Incompetence
Complacent
Competence
Unconscious
Competence
Conscious
Incompetence
Conscious
Competence
‘Achilles
Syndrome’
Supervision – Psychoanalytic and Jungian perspectives. Edited by Petruska Clarkson, 1998 Whurr, London. Chapter 9. An intervention priority
sequencing model for supervision. Petruska Clarkson pages 121-135
95
96
Hard-learned Lessons
SINGLE
SESSION
THERAPY
Steve Cottrell
•
•
•
•
•
•
Three missed appointments = discharge (usually)
Whoever cancels the session, rearranges it
Helpers (nearly) always initiate
Single-session time frame
Strengths and solution focus
Goal setting is often the hardest part
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98
IAPT Activity (NE England)
Single-Session Therapy
• 21.2% attended only 1 session
• Of those attending 2 or more sessions, 4844 (44.9%)
completed the treatment
• 1961 (23%) dropped out after 2 or more sessions
• 861 (8%) were ‘unsuitable for IAPT’ after 2 or more sessions
• Many come for only one, most three to six sessions
• Most leave before postulated therapeutic mechanisms have
had time to come into play - ‘rapid improvers’
• People have considerable powers of spontaneous
recuperation
• Patients belong to social networks which facilitate (or
impede) recovery
• Patients mull over sessions before, after and in between so
long as they’re psychologically in contact with the treatment
• Single session attenders labeled ‘DNA’ or ‘drop-outs’ etc
Muralikrishnan Radhakrishnan et al 2011
97
99
100
•
•
•
•
•
•
•
•
•
Now is all there is
The client is the expert in their life
Listen – it’s all in there
Not ‘how to fit 10 sessions into one’ rather how to
maximise each session so it is a therapeutic experience
There’s not much time, so don’t rush
Each session has a beginning, middle and end
End on a positive
Increase developmental direction
Therapy is not the only way people change; many things are
therapeutic
•
•
•
•
•
•
•
•
Build optimism
Teach skills
Focus on strengths
Validate autonomy, health, independence, ability
Change is constant and inevitable
Small changes result in bigger changes
Use goals and scaling questions
What would you have to do / what would have to happen
for you to say ‘that was time well spent’?
102
101
Egan
• Stage 1: Exploration - The helper helps the client explore
areas of concern
• Stage 2: Developing new understanding / preferred
scenarios - The helper's enable the client to see him /
herself from different perspectives and develop deeper
understanding
• Stage 3: Action - In the third stage, the helper's role is to
assist the person to translate goals into specific action plans
Steve Cottrell
NICE & CCBT
THE CURRENT STATE
OF NICE GUIDANCE
RELATING TO CCBT
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103
Considered by NICE
104
Beating the Blues (Ultrasis plc.)
• Depression
• CBT-based for people with anxiety and / or depression
• 15-minute introductory video and eight 1-hour
interactive computer sessions
• Sessions at weekly intervals in routine care settings
• Homework projects are completed between sessions,
weekly progress reports delivered to the healthcare
professional at the end of each session
– Beating the Blues - Ultrasis plc.
– COPE
– Overcoming Depression: A 5-areas approach (Calypso)
Media Innovations
• Anxiety
– Fear Fighter - ST Solutions
– OC Fighter (formerly BTSteps) - ST Solutions
Serenity Programme 2013
105
COPE (ST Solutions Ltd.)
106
OD (Media Innovations Ltd.)
• For non-severe depression
• COPE was developed as an IVR plus workbook-based
system - also available as a network version (netCOPE)
• A 3-month programme with five main treatment
modules
• People can phone as and when they wish
• Overcoming Depression: a Five Areas Approach –
available as a CD-ROM-based CBT system for people with
depression
• Six weekly sessions of 45 – 60 minutes
• Sessions are delivered in a mixture of text, cartoon
illustrations and animation
• Practitioner reviews the person's use of the disc on three
occasions over the course
107
108
FearFighter (ST Solutions Ltd.)
OCFighter (ST Solutions Ltd)
• A 9-step CBT-based package for phobias, panic and
anxiety disorders
• Originally developed for stand-alone computer, later
developed for use on the Internet
• Brief therapist contact, 5 minutes before and up to 15
minutes after each session
• Therapist contact by telephone or e-mail for web version
• BTSteps (now OCFighter) a 9-step CBT-based self-help
programme for OCD
• BTSteps developed as an IVR* system plus workbook, an
Internet version is under development and will obviate
the need for IVR and workbook, helpline support is
provided
* Interactive Voice Response
Steve Cottrell
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02/02/2014
109
NICE Technology Appraisal 51
110
ACD-1* – Key Points
• Depression and anxiety: computerised cognitive
behaviour therapy (CCBT)
• Issued in 2002
• Replaced by TA97 in 2006
• CCBT (Beating the Blues, Cope, Overcoming Depression)
is recommended for the treatment of mild and moderate
depression
• A judgement that as CBT is a known and effective
approach for depression then CCBT packages as a whole
are likely to produce similar positive ‘group effects’
* Appraisal Consultation Document
111
NICE Technology Appraisal 97
112
ACD-2 – OIR*
• Computerised cognitive behaviour therapy for
depression and anxiety
• Review of Technology Appraisal 51
• Issued in 2006, modified in 2013
• Replaced TA51 'Depression and anxiety: computerised
cognitive behaviour therapy (CCBT)'
• ‘Cope’ and ‘Overcoming Depression’ not recommended
for the treatment of depression except as part of ongoing
or new clinical trials… gathering data on costs and
benefits…compared to an appropriate comparator
• OCFighter not recommended for the treatment of OCD,
except as part of ongoing or new clinical studies
* Only in Research
113
RCT Emphasis 1 of 2
114
No ‘Class Effect’
• ‘There is no RCT evidence for COPE or Overcoming
Depression for the management of depression.
Therefore, the Committee could not establish with a
reasonable degree of certainty that either of these
packages is a clinically or cost-effective method of
treating people with depression over and above other
management options such as TAU*’
• ‘Furthermore, it was not able to conclude that the CCBT
packages for depression could be considered to be
equivalent as in a 'class', because of the differences
between the packages' presentation, style and
complexity’
* Treatment as usual
Steve Cottrell
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02/02/2014
115
BTSteps RCT
• ‘The Committee considered the RCT evidence for BTSteps
for the management of OCD in which BTSteps was
compared with TCBT and relaxation. The Committee
noted that in the randomised clinical trials BTSteps was
never more effective than TCBT. It also noted that
patients were more satisfied with TCBT than with
BTSteps’
Response to consultee, commentator and public
comments on the ACD-2, 2005
117
Media Innovations 1 of 2
118
Media Innovations 2 of 2
• ‘The current wording … makes a de facto judgement that
a class effect for CCBT does not exist and reverses the
thrust of the original 2002 review’
• ‘This is a major and unwarranted decision which will
significantly reduce development in this area, produce a
monopoly situation, and importantly reduce patient and
practitioner choice’
• ‘The removal of any form of recommendation for
Overcoming Depression or COPE will create an effective
monopoly position for one commercially developed
package …’
119
ST Solutions
• ‘The committees ' recommendation to not recommend
OCFighter despite the strong evidence is likely to cause
harm to the thousands of patients who will not be
treated due to lack availability of services. The NHS is
unable … to provide CBT services to 75% of the patients
who require CBT treatment and who are in hospital.’
Steve Cottrell
120
Ultrasis
• ‘The revised document is, in general, an accurate
reflection of the evidence base for CCBT and will
stimulate appropriate and informed provision of the
technology in the NHS and beyond’
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02/02/2014
121
122
Updates
Research Recommendations 1 of 3
• Recommendations in TA97 relating to the treatment of
depression have been replaced by recommendations in
the two depression clinical guidelines (CG90 & CG91, and
in CG123 in 2011)
• Recommendations relating to the treatment of anxiety
disorders been replaced by entries in the GAD & Panic
Disorder guideline (CG113) in 2011, and the Social
Anxiety guideline (CG159) in 2013
• The clinical and cost effectiveness of two CBT-based lowintensity interventions (CCBT and guided bibliotherapy)
compared with a waiting-list control for the treatment of
GAD and Panic Disorder
123
124
Research recommendations 2 of 3
Research recommendations 3 of 3
• Future studies should be RCTs & include an ITT* analysis,
to take account of drop-outs, and record and report any
adverse effects … They should also collect appropriate
information on costs and health-related quality of life –
data should be collected using generic preference-based
measures (in conjunction with condition-specific
instruments) because they facilitate the calculation of
QALYs **
• Pragmatic RCTs for CCBT packages in a stepped-care
programme
• Comparisons of CCBT with other self-help comparators
e.g. bibliotherapy and exercise
• Comparisons of CCBT with placebo
• Comparisons of CCBT with brief and longer duration
TCBT* as well as group TCBT
• Head-to-head trials between the packages for depression
* Intention-to-treat
** Quality adjusted life-year
* Therapist-delivered Cognitive Behaviour Therapy
125
126
Thanks for Listening!
Questions?
Steve Cottrell
21
02/02/2014
128
Bibliography
•
•
•
•
•
•
•
•
•
•
•
NICE Appraisal Consultation Document – CCBT
NICE Appraisal Consultation Document 2 – CCBT (review)
Response to consultee, commentator and public comments on the ACD
Depression in adults: The treatment and management of depression in adults (CG90)
Depression in adults with a chronic physical health problem: Treatment and management
(CG91)
Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults:
Management in primary, secondary and community care (CG113)
Social anxiety disorder: Recognition, assessment and treatment (CG159)
NICE Guide to the single technology appraisal process (2009)
NICE Informing a decision framework for when NICE should recommend the use of health
technologies only in the context of an appropriately designed programme of evidence
development (2012)
Guidance on the use of computerised cognitive behavioural therapy for anxiety and
depression (TA51, 2002)
Computerised cognitive behaviour therapy for depression and anxiety: Review of Technology
Appraisal 51 (TA97, 2013)
Steve Cottrell
References
Clarkson, P (1990) A multiplicity of psychotherapeutic relationships. British Journal of Psychotherapy 7(2): 148-63.
Clarkson, P (1992) Transactional Analysis Psychotherapy: An Integrated Approach. London: Routledge.
Clarkson, P (1994) The Achilles Syndrome: The Secret Fear of Failure. Shaftesbury: Element.
Clarkson, P (1995) The Therapeutic Relationship in Psychoanalysis, Psychology and Psychotherapy. London: Whurr.
Clarkson, P (1996) The Bystander (An End to Innocence in Human Relationships?). London: Whurr.
Clarkson, P. (1997a) Conditions for excellence - the coincidentia oppositorum of the inferior function, in On the
Sublime (in Psyche's World) (ed. P. pp. 219-43. London: Whurr.
Clarkson, P (1997c) Supervision in counselling, psychotherapy and health: an intervention priority sequencing model.
European Journal for Counselling, Psychotberapy and Health, 1.
Clarkson, P. and Kellner, K. (1995) Danger, confusion, conflict, and deficit: a framework for prioritising organisational
interventions. Organisations and People 2(4): 6-13.
Egan, G. (1998) The skilled helper: a problem-management approach to helping. Brooks / Cole.
Freud, S. (I960) The psychopathology of everyday life. Standard Edition 6. London: Hogarth Press and Institute of
Psycho-Analysis.
McNamee, S. and Gergen, K.J. (1992) Therapy as Social Construction. London: Sage.
Radhakrishnan, M., Hammond, G., Jones, P.B., Watson, A., McMillan-Shields, F., Lafortune, L. Cost of Improving
Access to Psychological Therapies (IAPT) programme: An analysis of cost of session, treatment and recovery in
selected Primary Care Trusts in the East of England region. Behaviour Research and Therapy 51 (2013) 37-45.
Robinson, WL. (1974) Conscious competency - the mark of a competent instructor. Personnel Journal 53: 538-9.
Safran, J.D. (1993) The therapeutic alliance rupture as a transtheoretical phenomenon: definitional and conceptual
issues. Journal of Psychotherapy Integration 3(1): 53-49.
Stewart, I. (1996) Signing off. Tate Magazine Winter: 80.
Thompson, A. (1990) Guide to Ethical Practice in Psychotherapy. Chapter 12. New York: Wiley.
Watkins, C.E. Jr (1997) Handbook of Psychotherapy Supervision. New York: Wiley.
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