Month: February 2016

Panic Disorder Management – a problem based learning case study

Posted on by happii

Often, when we are presented with a case it can be difficult to find a way forward. To aid clinical decisions, it is sometimes necessary to break down the decision making process into stages. The problem based learning task below does just that. Here I was given a case study and we methodically worked through the problem to get to a solution.

Reena fears that she is experiencing the precursors to a heart attack. Reena avoids going to the gym, or out of the house alone, other than to work. Reena carries out safety behaviours whilst driving. Her GP feels that physical symptoms are due to panic attacks and as such has recommended that Reena seek IAPT support. She has been assigned a PWP trainee which she is concerned about. She presents with mild depression and moderate anxiety symptoms.

Identify what you already know to work toward resolving the problem

  • Heart palpitations, racing and pounding are all symptoms of panic disorder (DSM-5, 2013)
  • Physical exertion (i.e. exercising at the gym) can bring on symptoms similar to those experienced when anxious or panicking
  • Avoidance of situations which may increase physical symptoms is common in clients who suffer from panic disorder (Richards & Whyte, 2011)
  • Seeking reassurance is common when facing an anxiety provoking situation
  • Reena has a supportive friend who she listens to, who may be able to support her in treatment if needed
  • It is a GP’s responsibility to investigate and ascertain whether the client’s heart is sound; a PWP, qualified or otherwise, is not able to make judgements regarding this
  • The recommended medications for panic disorder are SSRI and TCA antidepressants but psychotherapy should be he first port of call (NICE, 2011)

Identify what you need to know in order to work towards resolving the problems.

I would want to do a full assessment including:

  • Assessing risk
  • client’s history including triggers and previous incidences
  • how long symptoms have occurred
  • how quickly they peak and subside
  • nature of thoughts during palpitations
  • thoughts, emotions, physical sensations and behaviours during last instance of panic and whether this is typical
  • whether she worries about other health difficulties to assess for health anxiety
  • what thoughts go through her mind before going to go out to assess for agoraphobia
  • client’s goals and barriers to working towards those goals
  • the client’s attitude to starting to go to the gym, and going out alone again

I would also want a discussion with GP to understand extent of the investigations he has made, and also to collect a brief history to see if illness anxiety disorder could be evident

How and where you can access new information to lead towards the resolution of problems

  • Discussion with client
  • Discussion with GP
  • Mobile use when driving https://www.gov.uk/using-mobile-phones-when-driving-the-law

Treatment plan

  • Phone work initially if she felt unable to leave home
  • Full assessment
  • Psycho-education about the qualifications of PWP trainee and what they are trained for, education about tendency for catastrophisation, hyper-vigilance, avoidance and safety behaviours
  • Graded exposure to gym / going out alone / driving without safety behaviour
  • Behavioural Experiments if assessment indicated that self-monitoring or avoidance of gym was due to fear of symptoms
  • Cognitive Restructuring of catastrophic thoughts if detailed assessment indicated this would be necessary
  • Give educational material to housemate if permission given

Signposting

  • Education about law regarding mobile use while driving
2,280 Comments

Worry Time

Posted on by happii

Do you find yourself spending a vast amount of your time worrying? Do you spend too much time worrying? Do you worry about a huge variety of things, from ‘what will happen if?’ scenarios, to very real situations, to your health, to your family’s safety, to money, to work, to your appearance? Do you worry that you’re worrying too much? Do you want to stop worrying?

Here’s how to stop worrying excessively .

Worry is a very normal thing. Worry is a natural skill (and yes it’s a skill which we learn and develop), which protects us from harm. If we didn’t worry about our health we wouldn’t go to the doctor and we might get ill. If we didn’t worry about our exams, then we wouldn’t prepare for them and we might fail. It’s useful in helping survive and thrive and because of this we will never be able to get rid of it entirely.
But! We can learn to control it in 4 steps.

Step 1:
Identify what it is that you’re worrying about, and be as specific as possible. Write. It. Down.

Step 2:
Schedule some ‘worry time’ for later in the day and leave your worry until then. Worry time can be any time when you’ve got up to 30 minutes to devote to worrying. (Right before bed isn’t the best time because it might stop you thinking). It might help to distract yourself, or keep busy, or do something relaxing, but keep reminding yourself, “I’ll worry at worry time”

Step 3:
At worry time, get your pieces of paper out on which you’ve written your worries, and for each one, answer this question, is this a problem which is happening right now and which I need to do something about right now? In other words is it a hypothetical worry or is it a real worry? Hypothetical worries are things like, “what if I lose my job? ” or “do they like me?”. Real worries are things like “my car is broken down, what can I do?” or “I can’t pay this bill in time”.

Step 4:
If it’s a real worry, then problem solve it (I’ll add in some how to tips on how to do this at a later date).
If it’s not a real worry, then have a think about it if you like, but let it go, remembering that it’s natural to worry, but that if it isn’t something you can actually do something about, or if it’s something which might never happen, then it is futile to spend too much time thinking about it.
After 30 mins of worry time, stop, and do something else.

Repeat this every day, and often people find that they simply worry less and less because their brain realises that some worrying is pointless.

4,272 Comments

Which therapist should I choose?

Posted on by happii

So you’re feeling, low, anxious, scared, obsessive, self-critical, you’ve got low self esteem or maybe your relationship needs a fix.
You’d like some help.
You need a therapist.
But where to start looking?
What do you look for?
What qualifications should they have? How do I know they’re any good?

Here’s a step by step guide to choosing the right therapist. Some of the stages are quite complex so this page will link to further pages with more details.

Firstly, please understand that there are thousands of types of therapy out there, from hypnotherapy to cognitive behavioural therapy, solution focused therapy to crystal therapy. You name it, there’s a therapy named after it.
But just because it’s called a therapy, doesn’t mean it’s going to do you some good. Many therapies have very little scientific evidence to prove that they are in any way beneficial.

So.
Rule no. 1: Choose an effective therapy

Choose a therapy which has been shown to be scientifically effective. Generally, in treating clinical mental health and physical difficulties, follow the advice of the NHS (who check these things). Their advice can be found here, just search for the condition you’re dealing with.

Sometimes you’ll be dealing with a problem, issue or difficulty which hasn’t been reviewed by the NHS, might not have a name, or isn’t severe enough to require a clinical professional. So if you’re thinking “what kind of therapy do I need?” then click here.

And then of course, even if the therapy has been shown to be effective, if it is carried out by a therapist without the necessary skills it’s also unlikely to have a positive effect on you. Hence Rule no. 2…

Rule no. 2: Choose a therapist who has been accredited by their governing body.

Many health care professionals, are a member of HCPC which regulates professions such as art therapists, chiropodists / podiatrists, dietitians, occupational therapists, physiotherapists, psychologists and speech and language therapists. If your therapist is a member of HCPC (which you can check here) then you’re in safe hands.

However, some professions aren’t covered by HCPC. For these, check that they’re accredited members of the following organisations by clicking on their links:

Massage Therapy – voluntary regulation is made under CNHC
Cognitive Behaviour Therapy – accredited by BABCP and BACP
Psychotherapist – accredited by BACP
Counsellor / Counselling – accredited by BACP
Hypnotherapist – accredited by GHSC
Relationship Counselling / Counsellor – accredited by COSRT
Sexual Relationship Therapist / Counsellor – accredited by COSRT
Acupuncturist – accredited by BMAS, AACP, BacC, BAWMA, BRCP and AcuC
(Many non-medical acupuncture practitioners are also required to register with their local authority who check their premises and practices for safety. Please check with you local council for more information).

Rule no. 3: Don’t judge a book by its cover.

Ignore references, testimonials and the flashiness of their website. Many great therapists are useless at websites, but great at therapy. In a similar vein, it’s easy to create false testimonials, and actually quite difficult to get permission from real clients for good references, so don’t rely on these. If a therapist is properly validated (see above) then their supervisor will have checked the quality of their work and they will have had to submit evidence of the quality of their work, which is much more impartial than the quotes you can see on the website.

Rule no. 4: Talk to them and then go with your gut

Most therapists will be happy to talk over the phone with you before you commit to a first session. Some will even offer free first consultations.
And this is when you should consider… Can I work with this person? It is so important for there to be a positive relationship between you both so if you’re not feeling it, be brave and say no thank you.
They should be listening to you, not just talking.
They should be empathising with you so that you feel understood.
Each stage of treatment they should be explaining to you, and talking you through how they work so that you understand.
You should have choices too, of how to progress and how quickly to progress.
You should feel empowered as part of the journey, you shouldn’t feel that therapy is being done to you but with you.

Rule no. 5: Pricing is negotiable so agree this up front

Prices for therapy can range hugely from a voluntary fee (sometimes charities providing therapy will ask you to prove that you are receiving benefits first and then ask you to contribute whatever you can afford) to, well, the sky is the limit! A good average price of therapy at the moment is from £40 to £60 a session.
It can be quite a big financial commitment so don’t be afraid to ask lots of questions like :
How much is a session?
How long is a session normally?
Do I have to commit to a certain number of sessions?
If I cancel, is there a fee?
How late can I cancel?

Rule no. 6: A good therapist will encourage you to stop therapy.

What I mean by this is that you will know a therapist has done a good job if they can get you to the point where you feel able to go it alone and work independently, without their support. So ask upfront, how many sessions have your current clients received from you? How long it takes to recover is like asking how long is a piece of string, but as a rule of thumb, if working with CBT, on mild to moderate depression or anxiety, it might only take 6 sessions to teach you the techniques to get you on your feet again.

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“It was like being buried alive”: battle to recover from chronic fatigue syndrome

Posted on by happii

This article I found in The Guardian provides a real insight into what it can be like to experience chronic fatigue syndrome or ME.

It looks at a new way of looking at the disorders,  because we are finding,  more and more, that the brain and the body do not work separately, they are interlinked and one can affect the other.

Specifically, in CFS or ME, it is thought that the part of our brain which interprets our energy levels is out of sync. “It’s overestimating how fatigued you are, the fatigue that normally protects us from pushing ourselves too far might instead become a prison”.

The article talks about a new treatment for CFS or ME is now being considered called GET or Graded Exercise Therapy,  where patients are gradually exposed to very small amounts of exercise to build up their strength and energy levels.

Click here to read the original article.

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Fatigue & Concentration Tips

Posted on by happii

Neurons (the cells which make up our brain) are like other cells – they are living with their own metabolism.  They need oxygen and glucose to work and survive and when they’ve been working hard (thinking, concentrating, remembering, coping) they experience fatigue. When our neurons are fatigued, we will feel it too, our brain will work slower, make mistakes and struggle to keep up.  So this might mean we can’t find the right word, we don’t have the energy to control our temper and we might be irritable, we lack motivation and importantly we go for easy options such as cake not fruit (to get that glucose), bed not a book (to restore our reserves) and we start yawning (to get more oxygen).

All this sounds quite common sense doesn’t it? So, why, then are we so poor at recognising when our brain is fatigued? We are quick to notice when we’re physically exhausted, and we would often adjust our activities to suit; we might have a nap, take the weight off our legs, choose not to drive and other sensible decisions. I think, like everything to do with the brain, we just don’t understand it well enough. And because we (normal people) don’t understand it, we don’t think about it, don’t notice it and rarely make allowances for it. We just assume it will keep going regardless. Until it lets us down, and we fall asleep at the wheel, we say something nasty we didn’t mean to a loved one, or we stay up all night working inefficiently, ruining a piece of work because we can’t see that taking some time to recover might be provide a better return on time investment.

So what can we do to fight fatigue? Here I’ve written my 9 top tips for beating fatigue:

1. Avoid multi-tasking – if we ask our brain to concentrate on multiple things at once it simply does both tasks to a poorer level and runs out of resources quicker. So turn off the TV if you’re studying, don’t call your mum while you’re cooking and don’t have the music on when you’re parking.

2. Become more aware of your brain’s energy levels. I talk about mindfulness below as a way to relax but psychologists believe the true value of mindfulness is in becoming aware of your body and your mind. Taking time to notice your mind racing, and when it’s settled means that you become skilled at that, and when you notice is racing again you can quickly adjust your actions to help your brain and body out.

3. Help teach your mind to switch off. You can do this with mindfulness, or meditation, even yoga, which allows you to ground your mind and stay in the present. Ultimately, this is relaxation, and you can find your own way to do that, but thousands of people all over the world have found the practices above the most useful, and you don’t have to spend money to do it thanks to apps, YouTube and the rest of the internet.

4. Drink water, your brain needs it.

5. Eat slow release carbs, your brain needs them.

6. Avoid stimulants like caffeine, drugs and sugar because whilst they might give your brain cells a bit of a lift short term, the levels quickly drop and often to even lower levels than at the start.

7. Get some fresh, outdoor air, your brain needs the oxygen.

8. Instead of multi-tasking try change-tasking. Switch your tasks. This is because if your brain has been concentrating on one type of task, it will be using only certain regions of the brain, and they are the ones which are fatigued. By changing the nature of the task, (i.e from essay writing to cooking), you’re likely to be using different areas of the brain which are less fatigued and this then gives the rest of the brain time to recover.

9. Sleep

1,722 Comments

Motivation Tips

Posted on by happii

This is one of the most common difficulties reported by clients with depression. We all know how it feels too, there can be so many things to do, and what there is to do just doesn’t appeal to us. Even worse, what there is can be so overwhelming, we don’t even know where to start or if we can cope. People who don’t have depression can often mistake it for laziness, but it’s very different, because in reality, a lack of motivation can be so debilitating, it can prevent people from going to work, getting up, washed, dressed, eating, even paying bills.

So, how do you fix it?

Well, the way motivation works is a bit like a car battery, to keep you and your life going, you can’t leave it unused for any length of time, you’ve got to take it for a run around on a regular basis. That means keeping on keeping on! Simply doing something can give it a boost to keep it going the next day, and the next, and so on.

And what to do if you have no motivation at all? There is no easy answer, you just have to force yourself to push on through, and do something. You can’t wait for motivation to come along, because it won’t.

Sometimes people find antidepressant medication useful for a short time, because it can lift your mood for long enough for you to find the will to do something, and then once you’ve got the momentum, and are living more actively, people may find that, with guidance from their GP, they can reduce their medication because the motivation has returned.

But! If you want to boost your motivation, here are some motivation tips (the last one is the best):

  • Make a plan, and write it down
  • Tell someone about your plan
  • Make your plan realistic and achievable, it may help to break your plan down into small steps
  • When it comes to it, go with the plan, not the feeling
  • Follow the 5 minute rule: tell yourself that you’ll do it for 5 minutes, and if you hate it then you can stop after 5 minutes, but most people find that once started, they want to continue
477 Comments

Editable CBT worksheets

Posted on by happii

When I’m working with CBT based principles, I use a lot of CBT worksheets, and I like to give clients a choice of the format they can use. A lot of the time they like to have ready-printed sheets, but sometimes, they’re a bit more high-tech and prefer to edit them online using their smart phone, tablet or PC. Unfortunately, most of the CBT worksheets available online are in PDF format (and therefore not editable easily), so here are my versions, there are Windows Word CBT worksheets and Excel CBT worksheets which you can get as a free download if you click on the links!

COGNITIVE RESTRUCTURING

Thought Diary Log Worksheet (Cognitive Restructuring)

 

BEHAVIOURAL ACTIVATION

Activity Diary Log Worksheet (Behavioural Activation)

 

GRADED EXPOSURE

Hierarchy of Fears Worksheet (Graded Exposure)

 

4,602 Comments

Medication Management and Mental Health – a problem based learning case study

Posted on by happii

Often, when we are presented with a case it can be difficult to find a way forward. To aid clinical decisions, it is sometimes necessary to break down the decision making process into stages. The problem based learning task below does just that. Here I was given a case study and we methodically worked through the problem to get to a solution.

Identify, read and reflect upon the information supplied

Archie’s mother’s illness triggered his depression and anxiety and although she is recovered, his symptoms remain. He has been prescribed Citalopram 20mg but has some concerns about addiction but does not feel able to ask his GP about this and has not started taking them.

Identify what you already know to work toward resolving the problem

  • Diagnosed with moderate Depression (DSM-5, 2013)
  • Moderate Depression recommended treatment is low- intensity CBT based guided self help and / or antidepressant medication (NICE, 2009)
  • CBT has been shown to be as effective as antidepressant medication
  • Some antidepressants in the past have been known to be addictive but SSRIs such as Citalopram are not addictive
  • 20mg is a relatively low dose of Citalopram
  • Not everyone experiences side effects to antidepressants
  • Side effects to antidepressants often reduce within a few weeks of taking them
  • There is a lot of medication advice literature available from NHS and IAPT
  • Archie is motivated to get better
  • Archie seems to have a good relationship with his mother’s GP

Identify what you need to know in order to work towards resolving the problems.

  • Common side effects of Citalopram and likelihood of these
  • Whether Archie feels able to speak to his mother’s GP

How and where you can access new information to lead towards the resolution of problems

  • Information about SSRIs from NHS here
  • Incidences of Citalopram side effects from drugs.com here
  • Discussion with Archie about willingness to consult second GP

Treatment plan

  • Empathising and normalisation of concerns about mother and medication
  • Psycho-education about right to ask for different GP, or to change GP practice
  • Psycho-education about medication management, both in literature form and in discussion
  • Psycho-education about evidence base showing that CBT based treatment can be as effective as antidepressant medication
  • Psycho-education about depression and anxiety, and occurrence of NATs
  • CCBT, group or telephone Guided Self Help for depression in line with Healthy Minds service recommendations
  • Focus on Thought Challenging may be considered

Signposting

  • Signposting to reliable drug information websites (see above) may be appropriate
  • If mother’s health was deteriorating then signposting to care options, but at this stage it is not felt to be necessary
599 Comments

Graded Exposure – self reflection on a CBT intervention

Posted on by happii

When learning to carry out therapeutic interventions or treatments, it’s important to understand the mechanisms of the task in detail, and what better way to get to the bottom of that than by using the technique on yourself? Here I practiced a standard CBT intervention for anxiety, Graded Exposure, and reflected so that in the future I can improve the experience for clients in the future.

What is the background to the intervention you practiced?

I practiced Graded Exposure, which has its foundations in cognitive behavioural therapy. Cognitive Behavioural Therapy posits that our thoughts and behaviours can affect how we feel emotionally and physically, and that by modifying our behaviour and cognitions, we can help improve our physical and emotional wellbeing (Beck, 1979). Graded Exposure focuses on the behavioural aspect of this cycle and suggests that when people are feeling anxious, they may avoid doing things which cause them anxiety which in turn can maintain the fear cycle (Richards & Whyte, 2011). The intervention itself encourages individuals to identify activities which expose them to a related anxiety provoking situation, in increasing levels of difficulty and to remain in the situation until they witness their anxiety reduce naturally, without avoidance. With repetition, the individual habituates themselves to the feared activity or object and the fear response stops (Richards & Whyte, 2011). There is a large evidence base for exposure treatment of anxiety disorders (Hofmann & Smits, 2008; Norton & Price, 2007), many with a large effect size (Cox et al. 1992).

What did you find easy?

I found using the materials quite straight forward, the ladder or hierarchy of fears was simple to use, and once I had rated the anxiety level for each situation it was easy to put into order, to choose which one to do first and so on.

What did you find difficult? 

It was difficult deciding on an anxiety provoking situation that I was motivated to work on, particularly as in our Clinical Skills Supervision in service we were asked to consider a fear which was more complex (i.e. not spiders)

It was also difficult creating the individual steps of the ladder, as I had to be quite creative but also realistic as to what could be realistically simulated or set up within normal life limitations and resources

In addition, because the activities that I had chosen for the steps of the ladder were not situations that I had experienced in life before it was difficult to estimate the anxiety levels that they would produce

Carrying out the activities I chose took a lot of resources, time, a room, someone else to support me and I felt reluctant to carry this out because of these difficulties

Doing the activity was OK itself except it was hard to carry it out for long enough for the anxiety to reduce by 50%

Keeping going with the rest of the activities on the ladder was difficult because it took time, and keeping motivated for subsequent weeks was challenging

What parts were a learning experience for you and how will this guide future practice?

I learnt that this task is challenging because it can take a lot of organisation and motivation on the part of the client. In this way I would change my practice by:

  • encouraging clients to develop exposure options which are as easy as possible
  • talking about motivation tips
  • problem solving with the client in-situ if needed
  • scheduling the task in a diary to aid adherence to plan
  • reviewing progress each week and planning next week with client to keep momentum
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