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Serenity Programme Training
Helper TrainingDay two – updated 22-06-15
1
Slide22
Slide33
Slide4Contents
The ‘4P’ model
(Patient, Provider, Program, Problem)Communication typesThe relationshipCues and dynamicsJohn Suler – 6 characteristicsIntervention priority sequencingSingle-session therapyNICE guidance and CCBT
4
Slide55
Contacts
This work is licensed under a
Creative Commons Attribution-
NonCommercial-ShareAlike 3.0 Unported License.
SERENE.ME.UK/HELPERS
Slide6Welcome!
What would you have to
do, or what would have to happen here today for you to be able to say: ‘That was time well spent!’
6
Slide7The ‘4P’ Model
7
Slide8The ‘4P’ Model
8
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.
Slide9The ‘Patient’
NICE recommends that anyone meeting the criteria
for GADPanic DisorderPersistent Sub-threshold DepressionMild to Moderate Depression Should be offered the choice of CCBTThere is little formal evidence that younger people in general are more suited to CCBT …
9
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.
Slide10Generations
Generation
Birth DateAge at 2013Generation ‘Z’After 199419 or lessGeneration ‘Y’1977 - 199320 - 36Generation ‘X’1965 - 197637 - 48Younger Boomers1955 - 196449 - 58Older Boomers1946 - 195459 - 67Silent Generation1937 - 194568 - 76G I GenerationBefore 193677 +
10
Slide11The ‘Patient’
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?
11
Generations
Age (Years)
Baby Boomers
49 - 67
Generation ‘X’
37 - 48
Generation ‘Y’
20 - 36
Generation ‘Z’
Less than 19
Slide1212
Who does What?
Slide1313
http://www.statista.com/topics/840/smartphones/chart/1489/the-generational-divide-in-cell-phone-use/
Slide14‘Boomers’(
49 - 67 years)
80% are online, 30% own smartphones60% lost assets in economic downturnThe last generation to own a home on a single wage?42% are delaying retirement, 25% say they'll never retireWitnessed the birth of the home PC‘Loyal workaholics’Relatively high disposable incomeSome ‘GUAVA’ - ‘Grown Up And Very Affluent’Appreciate ‘lifestyle tech’Appreciate 1:1 paradigm – e.g. SkypeGovt, health and financial info: ‘Trusted sites’
14
Slide15‘A worldview based on change’
(Christine Henseler, 2012)Relatively high educational attainment‘Manufacturing’ to ‘service’ economic changeWitnessed the birth of the InternetTeens / young adults during Thatcher era (1979 – 1990) First ‘latch-key’ generation (working mothers)Independent, resourceful & self-sufficientParental divorce & redundancyGrown with computers
15
Generation ‘X’ (
37 - 48 years)
Slide16Generation ‘Y’ (20 - 36 years
)
The ‘Millennials’97% have a computerTechnologically sophisticatedWitnessed the birth of social media and Internet icons – Facebook, Twitter, LinkedIn, MySpace, YouTube, GoogleRemember the ‘dot com bubble’ 1997 - 2000Dual income / single parent householdsDecline of faith & religionWork / personal fusionBYOD
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Slide17Generation
‘Z’ (19 years or less)
Technologically agnosticThe rise of the ‘smartphone’Always ‘connected’, always ‘on’Relatively low attention spanFacebook, twitter and textingPrivate / public blurringAccessibility of FE options?Employment opportunities?
17
Slide18Trends in Internet Usage
The fastest growth in social networking is in people 74
and older, rising from 4% to 16% between 2008-2010Searching 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 online62% of adults living with one or more chronic disease go online52% of adults living with two or more chronic diseases go onlineThese trends apply when increasing age is controlled for
18
Pew Research
Center's
Internet & American Life Project, April 29-May 30, 2010 Tracking Survey
Slide19The
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)
19
Slide20Expectations
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’Macdonald et al, 2007
20
Slide21Attrition
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
21
*
Randomised Control Trial
Slide22The Problem
Anxiety disorders (GAD, Panic Disorder, Phobias, PTSD, Social Anxiety, OCD)
DepressionOthers …The need for support can vary by disorderAnxiety can often benefit from minimally guided self-helpDepression may require additional support 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
22
Slide23The Program
Software has ‘
personality’ - users report a therapeutic alliance with CCBT programs (Barazzone et al, 2012)People relate to both hardware and softwareHuman-computer interaction and ergonomicsUnderstanding of critical factors is in early stagesBehavioural changeInterpersonal componentOptions to personalisePlacebo / halo effectGeneralisation
23
Slide2424
Barazzone, N, Cavanagh, K, and Richards, D.A. (2012). Computerized cognitive behavioural therapy
and the
therapeutic alliance: A qualitative
enquiry. Br J.
Clin
.
Psy
.
I
ncluded were BTB, MG & LLTTF
Slide25The 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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Slide26The Provider
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Slide27Driving Forces (+)
Restraining Forces (-)
Actions to reduce the Restraining
Forces
Force Field
A
nalysis
W
orksheet
Slide28Force
Field Analysis - Exercise
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
Slide29CommunicationTypes
29
Slide3030
Slide31Communication
types
Synchronous communicationInstant messaging e.g. Google Talk TMTelephoneVirtual environments e.g. Second Life®Video and audio links e.g. Skype TMAsynchronous communicationEmailBulletin boardSMS (text messaging)
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Slide32Benefits of asynchronous
communication
Fewer difficulties with managing an appointment time or working across different time zonesThe convenience of replying when you're ready and able to replyA ‘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
32
Slide33Challenges
with asynchronous communication (1)
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-mailsThere may be a reduced feeling of ‘presence’ because the participant and helper are not working together in the same momentSome of the spontaneity of interacting ‘in the moment’ is lost, along with what spontaneous actions can communicate about a person
33
Slide34Challenges with asynchronous
communication (2)
There may be some loss of the sense of commitment that meeting ‘in the moment’ can createPauses 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
34
Slide35Benefits of synchronous
communication
The ability to schedule sessions defined by a specific, limited period of time & the boundaries implicit in an appointmentA feeling of ‘presence’ created in real timeInteractions may show more spontaneity, resulting in more uncensored disclosures by the participantMaking the effort to be with the person for a specific appointment may be seen as a sign of commitment and dedicationPauses in the conversation, coming late to a session and ‘no-shows’ are not lost as temporal cues that may have psychological meanings
35
Slide36Challenges with synchronous communication
The difficulties and inconvenience in scheduling a session at a particular time, especially if the participant and
helper are in different time zonesThere may be less ‘reflective space’ - the time between exchanges to think and compose a considered responseIn 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
36
(Adapted from http://users.rider.edu/~suler/psycyber/therapy.html accessed 01-12-12)
Slide37TheRelationship
37
Slide38Beginnings
The
first stage in delivering a computer mediated approach is information gathering. Some questions we may want to consider are: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?
38
Slide39The C
ontract
The contract defines at least two important aspect of the relationship:The ‘business’ contract – defines the frequency of meetings, duration, payment etc.The ‘therapy’ contract – helps define a focus and goals for the interventionDuring initial contact, or early in the relationship, several activities are often helpful …
39
Slide40Clarifying
the Boundaries
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?
40
Slide41Clarifying the
Purpose
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?
41
Slide42Claude Steiner – 4 Requirements
(1974)
Mutual consent - involves an offer and an acceptance arrived at by negotiationConsideration - includes the benefits conferred, which may be bargained for and that are agreed upon. Each puts something of value into the relationshipCompetency - both parties will be competent to carry out what has been agreed upon in the contractLawful 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)
42
Slide43Expectations
What does the
helper expect from the participant?Punctuality?Clear goals?Demonstrable commitment?Work outside sessions?What else?
43
Slide44A Multiplicity of Relationships
The working alliance
The transference relationshipThe reparative, or ‘developmentally-needed’ relationshipThe person-to-person relationshipThe transpersonal relationship
44
Slide45The
Working Alliance (1 of 2)
The working alliance is the fundamental bond between helper and participantThe alliance develops within the framework of a clear business contractHelpers support the development of the alliance by using active listening skills and by modelling a collaborative relationship
45
Slide46The Working
Alliance (2 of 2)
Bordin (1979) proposes three essential aspects of the working allianceThe collaborative setting of goalsThe joint agreement on tasksThe development of a human relationship or bond
46
Slide47ZPD
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
47
Slide48The
Transference Relationship 1
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
48
Slide49The 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)
49
Slide50Transference – 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
personA 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 relationshipsAll relationships will be influenced by transference phenomena, those of helpers and participants alike
50
Slide51Transference – Types 2
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 relationshipIn the presence of intense transference, longer term psychological therapy may be required
51
Slide52Transference - Clarkson
Proactive
transference: What the participant brings to the relationship / the participant’s projections of past experiences onto the helperProactive countertransference: What the helper brings to the relationship / the helper’s transference towards the participantReactive transference: What the participant reacts to because of what the helper brings to the relationshipReactive countertransference: What the helper reacts because of what the participant brings to the relationship
52
Slide53The 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: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)
53
Slide54The Reparative Relationship
Missing
elements, which may be provided in the reparative relationship, identified by Clarkson (1995, p235) as:ContainmentWitnessCare
54
Slide55The
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-to-person relating as a desirable goal of psychological therapy Authenticity means being true to one's own personality, spirit, or character (Miriam-Webster, 2012)
55
Slide56The
Person-to-Person Relationship
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)
56
Slide57The Person-to-Person Relationship
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 relationshipTo 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
57
Slide58The
Transpersonal Relationship 1
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’
58
Slide59The 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
59
Slide60Cues anddynamics
60
Slide61Non-Proximal Therapy
Psychological therapy provided without being in the same room as the participant (non-proximal therapy) brings unique
challengesThe fewer the cues there are about the emotional state of the participants, the more challenges there may beGenerally, 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
61
Slide62A
Hierarchy of Cues
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
62
1Face-to-face interactionMore cues2Holographic or virtual reality3Video link 4Telephone 5Shared virtual environments 6Instant messaging 7Email 8LetterFewer cues
Slide63Projection –
‘Filling In’ Perceptual Gaps
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
63
Slide64Transference to the M
achine
Some people see computers as helpful, they may view their smartphones, tablet computers or personal devices as personal, important and intimately their ownOthers 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
64
Slide65Four-cornered Contracts
I
n 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
65
A
T
H
P
Slide66Disintegration and
Primitive Processes
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 damagedNon-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
66
Slide67Disintegration and
Primitive Processes
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 well-documented adverse events, for example the encouragement of online suicide and the pathology of ‘thinspiration’ sitesThe occurrence of ‘flame wars’ exhibit primitive splitting and denigration – what may be termed ‘the cruelty of crowds’
67
Slide68Disintegration and
Primitive Processes
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 scrutinisedThe 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
68
Slide69Identity I
ssues
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 emailIt is relatively trivial for people to impersonate others in an email exchange (‘spoofing’) and a serious breach of confidentiality can ensue
69
Slide70Identity I
ssues
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
70
Slide71Bystander
Apathy
‘Bystander apathy’ is a term coined after the murder of Kitty Genovese in New York in 1964Kitty 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
71
Slide72Bystander
Apathy
Investigation revealed that about a dozen individuals nearby had heard or seen at least some part of the attackKitty’s death prompted research into ‘bystander apathy’ – the idea that someone else will do something about a situation, leading to abdication of personal responsibilityResponsibility 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
72
Slide73William
Melchert-Dinkel
William Melchert-Dinkel, 49, of Faribault, USA was convicted in 2011 of two counts of aiding suicideMelchert-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
73
Slide74William
Melchert-Dinkel
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 themselvesHe told police he did it for the ‘thrill of the chase’
74
Slide75Anonymity,
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 interactionsThis may be facilitated by anonymity, by positive transference and by the disinhibition afforded by the wearing of the electronic equivalent of a mask
75
Slide76Anonymity,
Immediacy and Disclosure
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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Slide77John Suler: SixCharacteristics
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Slide78John Suler – ‘Six Characteristics’
John
Suler (2004) has written about six characteristics of the Internet which can lead to change in behaviour:You don’t know meYou can’t see meSee you laterIt’s all in my headIt’s just a gameWe’re all equalhttp://users.rider.edu/~suler/psycyber/psycyber.html
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Slide79Dissociative Anonymity
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
79
Slide80Invisibility
You
can’t see me …Allows for misrepresentation of the self e.g. male posing as female & vice versaInvisibility 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
80
Slide81Asynchronicity
See you
later …Asynchronicity – face-to-face we receive rapid feedback about the effects our words are havingWithout 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
81
Slide82Solipsistic
Introjection
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
82
Slide83Dissociative
Imagination
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 traceIt 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
83
Slide84Neutralising
Status
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 screenThere 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’
84
Slide85Telepresence
Telepresence
- the experience of being fully present at a live real-world location remote from one's own physical locationScreen size and ‘immersive experience’We don’t see ourselves as operating a telephone …The more ‘invisible’ the technology, the more immersive the experiencePotential for remote emotional work?
85
Robonaut
2
Slide86Mirroring
86
Slide87Mirroring
87
Say ‘hello’ without raising the eyebrows
Mirror postures
Slide8888
88
Slide89Interventionprioritysequencing
89
Slide90Intervention 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
90
Slide91Danger
T
he conscious or unconscious preoccupation of the system is with survival issues. These will often make work with other themes ineffectiveIssues concerning homicide, suicide, psychosis, risk to others and ethical concerns almost always need to be dealt with firstPeople 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
91
Slide92Confusion
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 relationshipsEngaging in conflict resolution when the system is unclear about the nature, consequences and significance of conflict is often a waste of time and effort
92
Slide93Conflict
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 behaviourWorking too hard with high blood pressure, while being reluctant to sacrifice what is felt as the adrenaline rush of workKnowing that exercise will help depression, yet feeling too low to exercise
93
Slide94Deficit
Issues
to do with replenishment, knowledge or skills deficits are most likely to be effective if the previous stages have been clearedPriorities when meeting a deficit are first to establish what people already have as resources, skills, training, and optionsFor 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
94
Slide95Development
I
ncreasing complexity, effectiveness, capacity and the range and flexibility of understandings, sensibilities & behaviourThe 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 researchWhen 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
95
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
Slide9696
Complacent Competence
Reflective Competence
‘Achilles Syndrome’
Slide97Singlesessiontherapy
97
Slide98Hard-learned Lessons
Three missed appointments = discharge (usually)
Whoever cancels the session, rearranges itHelpers (nearly) always initiateSingle-session time frameStrengths and solution focusGoal setting is often the hardest part
98
Slide99IAPT
Activity (NE England)
21.2% attended only 1 sessionOf those attending 2 or more sessions, 4844 (44.9%) completed the treatment 1961 (23%) dropped out after 2 or more sessions861 (8%) were ‘unsuitable for IAPT’ after 2 or more sessions
99
Muralikrishnan
Radhakrishnan
et al
2011
Slide100Single-Session Therapy
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 recuperationPatients belong to social networks which facilitate (or impede) recoveryPatients mull over sessions before, after and in between so long as they’re psychologically in contact with the treatmentSingle session attenders labeled ‘DNA’ or ‘drop-outs’ etc
100
Slide101Single-Session Therapy
Now
is all there isThe client is the expert in their lifeListen – it’s all in thereNot ‘how to fit 10 sessions into one’ rather how to maximise each session so it is a therapeutic experienceThere’s not much time, so don’t rushEach session has a beginning, middle and endEnd on a positiveIncrease developmental directionTherapy is not the only way people change; many things are therapeutic
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Slide102Single-Session Therapy
Build
optimismTeach skillsFocus on strengthsValidate autonomy, health, independence, abilityChange is constant and inevitableSmall changes result in bigger changesUse goals and scaling questionsWhat would you have to do / what would have to happen for you to say ‘that was time well spent’?
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Slide103Egan
Stage 1:
Exploration - The helper helps the client explore areas of concernStage 2: Developing new understanding / preferred scenarios - The helper's enable the client to see him / herself from different perspectives and develop deeper understandingStage 3: Action - In the third stage, the helper's role is to assist the person to translate goals into specific action plans
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Slide104NICE & CCBTThe Current state of NICE Guidance relating to CCBT
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Slide105Considered by NICE
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Depression
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
Slide106Beating the Blues (Ultrasis
plc.)
CBT-based for people with anxiety and / or depression15-minute introductory video and eight 1-hour interactive computer sessionsSessions at weekly intervals in routine care settingsHomework projects are completed between sessions, weekly progress reports delivered to the healthcare professional at the end of each session
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Slide107COPE (ST Solutions
Ltd.)
For non-severe depressionCOPE was developed as an IVR plus workbook-based system - also available as a network version (netCOPE)A 3-month programme with five main treatment modulesPeople can phone as and when they wish
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Slide108OD (Media
Innovations Ltd.)
Overcoming Depression: a Five Areas Approach – available as a CD-ROM-based CBT system for people with depressionSix weekly sessions of 45 – 60 minutesSessions are delivered in a mixture of text, cartoon illustrations and animationPractitioner reviews the person's use of the disc on three occasions over the course
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Slide109FearFighter (ST Solutions
Ltd.)
A 9-step CBT-based package for phobias, panic and anxiety disordersOriginally developed for stand-alone computer, later developed for use on the InternetBrief therapist contact, 5 minutes before and up to 15 minutes after each sessionTherapist contact by telephone or e-mail for web version
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Slide110OCFighter
(ST Solutions Ltd)
BTSteps (now OCFighter) a 9-step CBT-based self-help programme for OCDBTSteps 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
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*
Interactive Voice Response
Slide111NICE
Technology Appraisal 51
Depression and anxiety: computerised cognitive behaviour therapy (CCBT)Issued in 2002Replaced by TA97 in 2006
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Slide112ACD-1* – Key Points
CCBT (
Beating the Blues, Cope, Overcoming Depression) is recommended for the treatment of mild and moderate depressionA 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’
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* Appraisal Consultation Document
Slide113NICE
Technology Appraisal 97
Computerised cognitive behaviour therapy for depression and anxietyReview of Technology Appraisal 51Issued in 2006, modified in 2013Replaced TA51 'Depression and anxiety: computerised cognitive behaviour therapy (CCBT)'
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Slide114ACD-2 – OIR*
‘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 comparatorOCFighter not recommended for the treatment of OCD, except as part of ongoing or new clinical studies
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*
Only in Research
Slide115RCT Emphasis 1 of 2
‘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*’
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*
Treatment as usual
Slide116No ‘Class Effect’
‘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’
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Slide117BTSteps 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’
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Slide118Response to consultee, commentator and public comments on the ACD-2, 2005
Slide119Media Innovations 1 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’
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Slide120Media Innovations 2
of 2
‘The removal of any form of recommendation for Overcoming Depression or COPE will create an effective monopoly position for one commercially developed package …’
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Slide121ST 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.’
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Slide122Ultrasis
‘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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Slide123Updates
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
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Slide124Research Recommendations 1 of 3
The clinical and cost effectiveness of two
CBT-based low-intensity interventions (CCBT and guided bibliotherapy) compared with a waiting-list control for the treatment of GAD and Panic Disorder
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Slide125Research recommendations
2 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 **
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** Quality adjusted life-year
*
Intention-to-treat
Slide126Research recommendations 3 of 3
P
ragmatic RCTs for CCBT packages in a stepped-care programmeComparisons of CCBT with other self-help comparators e.g. bibliotherapy and exerciseComparisons of CCBT with placeboComparisons of CCBT with brief and longer duration TCBT* as well as group TCBTHead-to-head trials between the packages for depression
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*
Therapist-delivered Cognitive Behaviour Therapy
Slide127127
Slide128Thanks for Listening!
Questions?
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Slide129Bibliography
NICE Appraisal Consultation
D
ocument – 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: R
ecognition, 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)
Slide130References
Barazzone, N, Cavanagh, K, and Richards, D.A. (2012) Computerized cognitive behavioural therapy and the therapeutic alliance: A qualitative enquiry. British Journal of Clinical Psychology.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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