CBT For Chronic Illness And Palliative Care: A Workbook and Toolkit Nigel Sage, Michelle Sowden, Liz Chorlton and Andrea Edeleanu Slide Set 1 Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

The CBT Model and Its Relevance in Cancer and Palliative Care Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

What is CBT? “…an active, directive, time-limited, structured approach” (Beck et al, 1979) The therapy works by helping patients to: “…recognise patterns of distorted thinking and dysfunctional behaviour. Systematic discussion and carefully structured behavioural assignments are then used to help patients evaluate and modify both their distorted thoughts and their dysfunctional behaviours” (Hawton et al, 1989) Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

There is nothing either good or bad, but thinking makes it so. Hamlet Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Man is troubled, not by events, but by the meaning he gives them. Epictetus (55-135 AD) Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Perception Reaction Event 1st Principle Accept interaction b/w If No - ie biology theology dynamics Then No CT Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Reaction Event Assumptions Beliefs Past Experiences Learning Standards Other information Rules of thumb Social pressures Reaction 1st Principle Accept interaction b/w If No - ie biology theology dynamics Then No CT Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

The Hot Cross Bun Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Environment Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Environment Environment Behaviour Physical Sensation Thoughts Emotion Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Helpful and Unhelpful Thoughts The Half Empty Glass  Empty bit So what? Is this helpful? Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Helpful and Unhelpful Thoughts The Half Full Glass This is helpful/useful to know Milk Washing Up Liquid Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Cognitive Behaviour Therapy (CBT) Helps us to : Recognise our internal dialogue Challenge its more incapacitating effects Develop a more constructive perspective Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

The Relevance of CBT in Physical Health Care Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

The Cognitive Behavioural Model Meaning Event Thoughts Decision making Behaviour The Cognitive Behavioural Model “There is nothing good or bad, but thinking makes it so” W. Shakespeare When Events impact upon us they trigger Thoughts. Meaning thoughts interpret the event: what’s going on, why it is happening, its “goodness”, its associations with our previous experiences etc. Decision Making thoughts: its importance, its relevance, what needs to be done about it etc. The Thoughts lead to Behavioural and Feeling responses. In the first instance the Behaviour will stem from the Decision Making thoughts, whilst the Feelings will stem from the interpretation in the Meaning thoughts. The Behaviour splits between: Reactive responses aimed at coping with the event itself Proactive responses which attempt to deal with and possibly influence the consequences and recurrence of the event. Feelings belong to one of two broad categories: Emotional responses of happiness, sadness, fear, excitement etc Physical responses of tension, tiredness, sweatiness, relaxation, nausea, cold etc In fact, it quickly becomes more complicated than that because the Behaviour will have a physical effect on the body and so will produce Feeling effects as well as producing new Events which trigger new thoughts. Similarly, Feelings will affect Decision Making thoughts and so change Behaviour. In other words, each part of the picture has an impact on every other part of the picture. Changing one element changes all the others – which is how Cognitive Behaviour Therapy works. Physical Reactions Emotions Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

I am completely useless and no one can help me. Diagnosis of cancer My life is over. I am completely useless and no one can help me. Take no action Withdraw from people Nausea Fatigue Depression Hopelessness Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

My life is going to change and I’m going to have to work at it. It’s going to be tough at times but my family and friends will support me during this difficult patch. Diagnosis of cancer Tell close friends Plan helpful changes Tense Energetic Sadness Determination Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

? My life is going to change and I’m going to have to work at it. It’s going to be tough at times but my family and friends will support me during this difficult patch. My life is over. I am completely useless and no one can help me. Take no action Withdraw from people Tell close friends Plan helpful changes Depression Hopelessness Trivial eg - not always! 1. C - Cut & dried B - Logical result of C A - Inevitable feeling from B 2. C - Gloomy but tryng to get persp. B - Acting “on instruction” not feelings A- Centred in now Sadness Determination ? Nausea Fatigue Tense Energetic Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Environment Behaviour Physical Sensation Thoughts Emotion Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Mr Catastrophic The patient has complained to my manager Alarm Thoughts Emotions Physical Sensations Behaviour The patient has complained to my manager Alarm Heart thudding Pace about, pick up phone and put down again I’ve really messed up Guilt Sinking feeling Brooding – staring into space, holding head My manager will be really angry Dread Stomach churning Go to toilet; avoid people and phone calls I’m going to be sacked or suspended for years Despair Drained of energy Slump on chair My friends will shun me Shame Skin prickles Hug self; seek fresh air My wife will leave me Hopelessness Feel sick Avoid going home – go to pub Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Miss Rational The patient has complained to my manager Alarm Thoughts Emotions Physical Sensations Behaviour The patient has complained to my manager Alarm Heart thudding Pace about, pick up phone and put down again I don’t really know why my manager called – best way to find out is to call her back and not wind myself up. Relief Calming physical sensations; release of tension Sit down; breath It’s interesting I thought of that patient; I’m obviously unhappy about how I handled that. Concern Increased tension; increased energy; nervy Fidgety; fiddle with pen; drum fingers on phone Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Miss Rational Thoughts Emotions Physical Sensations Behaviour Whether or not the patient has complained, I must think about lessons learnt from this event and perhaps take it to my next supervision. Interested; curious; feeling motivated Alert; active; release of tension Get out notebook; pick up pen; start writing I’ll phone the manager now and find out what she really wants. Anxious; determined Butterflies in stomach; sweaty palms; cold; dry throat Pick up phone and dial manager’s number Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Constructive thinking and behaviour Stuck/Rigid More Mental traps Failing actions Constructive thinking and behaviour Less Less More Helpful/Useful Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Environment Environment Behaviour Physical Sensation Thoughts Emotion Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

CBT For Chronic Illness And Palliative Care: A Workbook and Toolkit Nigel Sage, Michelle Sowden, Liz Chorlton and Andrea Edeleanu Publisher: John Wiley & Sons (2008) ISBN: 978-0470517079 Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008