Ouch! Eek! & Sigh! 02/18/04 Buch, Garrett & Bannerman 1

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1 Ouch! Eek! & Sigh! 02/18/04 Buch, Garrett & Bannerman 1

2 Divergent Treatment Solutions For Disability s Top Three Presentation, CARP BC 2004, February 18, 2004 Drs. Buch, Garrett & Bannerman Behavioural Health Care behaviouralhealthcare.com 02/18/04 Buch, Garrett & Bannerman 2

3 Thanks for the invitation! 02/18/04 Buch, Garrett & Bannerman 3

4 Overview Learning Objectives To identify 3 characteristics of an excellent assessment. To become acquainted with 3 treatment approaches. To generate a list of strengths & weaknesses of these 3 treatments to expedite case management & work return. To familiarize yourself with the outcome literature on 3 psychological disorders. To explore 3 future treatment trends. 02/18/04 Buch, Garrett & Bannerman 4

5 Not All The Same... 02/18/04 Buch, Garrett & Bannerman 5

6 Insight-Oriented Doggles... 02/18/04 Buch, Garrett & Bannerman 6

7 Hey, What s With The Finger... 02/18/04 Buch, Garrett & Bannerman 7

8 The Case of Ms. Bank Teller Age 40+, married, Caucasian bank teller, Gr. 12 Assaulted during armed bank robbery Child of alcoholic with pain problem Saw domestic violence Parents separated when she was 12 No psychological treatment Problem List: Ouch, Eek & Sigh Meds: lots of T3s, coffee. Effexor Marital strain Unhappy with management On short-term disability Doubts RTW due to safety risk 02/18/04 Buch, Garrett & Bannerman 8

9 ASSESSMENT 02/18/04 Buch, Garrett & Bannerman 9

10 Assessment We are all lunatics, but he who can analyze his delusion is called a philosopher. (Ambrose Bierce, ) If you keep doing what you re doing, you ll keep getting what you re getting (Dr. Bill Hrudy, BEEP Founder, WCB) Assess first! Assessment as story Assessment as therapy 02/18/04 Buch, Garrett & Bannerman 10

11 Assessment Types Psycho-Legal Intake 1-2 visits only First of many visits Comprehensive, costly Narrow, less costly Lots of testing A few, brief tests Diagnostic focus Treatment focus Atheoretical Follows theory 02/18/04 Buch, Garrett & Bannerman 11

12 Benchmarks of Excellence Appropriate Scope Clear Opinion Scientist/Practitioner Expertise 02/18/04 Buch, Garrett & Bannerman 12

13 THERAPY 02/18/04 Buch, Garrett & Bannerman 13

14 Insight-Oriented Therapy (With Apologies to Freud & Descendants) Origin of psychiatric symptoms Treatment objectives Empathy Transference & Countertransference Corrective emotional experience 02/18/04 Buch, Garrett & Bannerman 14

15 Insight-Oriented Tx for Ms. Teller Let her tell her story Safety, security & understanding through empathy How she interprets & understands her world Attention to transference Interpretation of transference/emotions to validate Deepen insight & self-awareness Working through inner conflicts & motivations to build a more coherent and integrated self Enlist the help of corrective emotional experiences 02/18/04 Buch, Garrett & Bannerman 15

16 THERAPY 02/18/04 Buch, Garrett & Bannerman 16

17 Cognitive-Behavioural Therapy Present-oriented, active, strategic, time-limited, and structured Psychoeducational, focused on skill acquisition Goal is to replace maladaptive perceptions with adaptive beliefs 02/18/04 Buch, Garrett & Bannerman 17

18 CBT Components for Ms. Teller Develop & share case formulation & treatment rationale Behavioural strategies (cbt) behavioural activation increase pleasant, mastery & social activities relaxation training: a self-calming tool to manage anxiety systematic desensitization 02/18/04 Buch, Garrett & Bannerman 18

19 CBT Components for Ms. Teller Systematic Desensitization Create a hierarchy or fear ladder CAP Principle: Challenge (don t overwhelm); Apply anxiety management techniques to reduce distress of challenge (never escape); Practice Exposure can begin in imagination (covert desensitization) then in real life trials (in vivo desensitization) 02/18/04 Buch, Garrett & Bannerman 19

20 CBT Components for Ms. Teller Cognitive Strategies (Cbt) mood monitoring identify automatic thoughts & cognitive distortions rational responding; formulating adaptive alternatives address underlying assumptions and maladaptive schema the consistent way in which the self or others are viewed core beliefs can increase our vulnerability to emotional distress 02/18/04 Buch, Garrett & Bannerman 20

21 CBT Components for Ms. Teller Relapse prevention normalize recurrence of some symptoms; attentional control anticipate triggers and stressors develop social supports review & rehearse adaptive coping strategies 02/18/04 Buch, Garrett & Bannerman 21

22 THERAPY 02/18/04 Buch, Garrett & Bannerman 22

23 EMDR Treatment method Treatment rationale Treatment phases (8) EMDR distinctives 02/18/04 Buch, Garrett & Bannerman 23

24 EMDR Treatment Phases Client History Preparation Assessment Desensitization Installation Body Scan Closure Re-evaluation 02/18/04 Buch, Garrett & Bannerman 24

25 EMDR Distinctives Bilateral activation Less talk Re-exposure to trauma important Client centred Somatic focus Change may be unpredictable 02/18/04 Buch, Garrett & Bannerman 25

26 Time for a Break 02/18/04 Buch, Garrett & Bannerman 26

27 What Do YOU Think? OPEN DISCUSSION 02/18/04 Buch, Garrett & Bannerman 27

28 Strengths & Weaknesses 02/18/04 Buch, Garrett & Bannerman 28

29 How to Compare Divergent Tx On a conceptual level On a technical level 02/18/04 Buch, Garrett & Bannerman 29

30 On A Conceptual Level... Explanation of etiology Maintaining factors Mechanism of clinical change role of insight role of language & cognition vs. experiential interventions nature & role of therapeutic alliance Emphasis upon here-&-now vs. developmental or historical factors Emphasis on environment vs. internal processes Emphasis placed on genetic or biological vulnerability 02/18/04 Buch, Garrett & Bannerman 30

31 On A Technical Level... Importance of identifying & pursuing specific treatment goals Importance of objective diagnosis & assessment of symptom severity Importance of obtaining specific information from patients & family members Identification of patient characteristics that are predictive of clinical improvement Role of case formulation in guiding selection of specific interventions Emphasis placed on therapeutic structure (problem focus) & directive intervention vs. unstructured & non-directive 02/18/04 Buch, Garrett & Bannerman 31

32 STUDIES 02/18/04 Buch, Garrett & Bannerman 32

33 Evaluating Outcome Research A typology is useful to classify & weigh research contributions Factors common across therapies account for a significant proportion of what is therapeutic Characteristics of patient, therapist & their relationship are important 02/18/04 Buch, Garrett & Bannerman 33

34 Treatment of Depression What s Effective? BT, CBT & IPT Type 1 (RCT) studies Meta-analytic reviews Combined psychosocial & medication Strongly supported by at least one major study SSRIs & several new compounds Support from Type 1 RCTs w/ placebo controls 02/18/04 Buch, Garrett & Bannerman 34

35 Treatment of PTSD What s Effective? Exposure, Anxiety Management Many Type 1 & 2 studies EMDR One Type 1 study & several Type 2 studies of civilian trauma vs controls Antidepressants Type 1 RCTs with placebo controls BT, SSRIs & EMDR Meta-analytic studies 02/18/04 Buch, Garrett & Bannerman 35

36 Tx of Pain Disorder What s Effective? CBT Individual or Group Reduces pain-related distress & disability (not pain) Several Type 2 RCTs Cognitive Therapy, Behavioural Therapy At least three Type 4 studies & several more Type 5 studies Antidepressants Reduce pain intensity Large number of Type 1 & Type 2 placebo-controlled RCTs 02/18/04 Buch, Garrett & Bannerman 36

37 TRENDS 02/18/04 Buch, Garrett & Bannerman 37

38 Multi-Modal Models Interdisciplinary Treatment Getting more per investment dollar? Individualization vs Generic Tx Modularized CBT: CbT vs. cbt Eclectic need not be a dirty word 02/18/04 Buch, Garrett & Bannerman 38

39 Brain, Mind & Body Neuroplasticity & the changing brain. How many new connections did you make today? Brain/Mind/Body in action An example Implications for treatmnet The neurobiology of posychotherapy 02/18/04 Buch, Garrett & Bannerman 39

40 Techno-Therapy Biofeedback traditional biofeedback, neurofeedback, hemoencephalography Digitized Psychology Self-help web sites & list-serves Web-based appointments, assessment & counselling The digital psychologist Virtual Reality being there, but not 02/18/04 Buch, Garrett & Bannerman 40

41 Remember... Please Visit Us & Get Slides! behaviouralhealthcare.com 02/18/04 Buch, Garrett & Bannerman 41

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