EVIDENCE-BASED FOCUSSED PSYCHOLOGICAL INTERVENTIONS

Major focussed psychological strategies shown to be evidence-based for a number of psychological disorders and included as focussed psychological strategies in the MBS for the Better outcomes in mental health care initiative.

Focussed Psychological Strategies

1. Psychoeducation

2. Motivational interviewing

3. Cognitive-behavioural therapy

Behavoural Assessment:
-to be advised

Behavioural interventions:
- behaviour modification
-exposure techniques
-activity scheduling

Cognitive interventions:
- cognitive therapy

4. Relaxation strategies

- progressive muscle relaxation
- controlled breathing

5. Skills training

- problem-solving skills training
- anger management
- social skills training
- communication training
- stress management
- parent management training

6. Interpersonal therapy

7. Relapse Prevention

-to be advised

Psycho-education

Does it work?
The hard outcome data on patient education is scanty but it is a major component of all good clinical care. There is good evidence that the more people understand about their illness and it's treatment the better they adhere to treatment plans. Psycho-education is a major component of all self-help programs (e.g., Lampe, 1996). Knowledge about the symptoms, the natural history of a disorder and the effective treatments has been shown to improve outcome (Craighead, et. al., 1998)

How do you do it?
1. 1. Remember to use words that the patient can understand. List the symptoms and signs that the patient has. List the diagnostic criteria for the disorder. Say that you think that the patient meets criteria for the disorder and relate it back to their symptoms.
2. Say it is a common the disorder (i.e. you are not alone), describe the natural history of the disorder and what improvements can be expected from treatment. Instill hope "many other people have benefited from this treatment"
3. List the treatments that work and outline the treatment plan you would recommend for this patient.
4. Invite questions and discuss.
5. Reinforce at subsequent consultations.

Psychoeducation, or what the doctor might say:

Below is an example the minimum that a GP might say when beginning a psycho-education session with a patient with the specified mental disorder.

F10: Alcohol abuse/dependence:
The recommendations for healthy drinking are less than14 drinks per week for women, or 28 drinks for men. It seems that you are drinking more than this. The problem with drinking at your level is that it can damage your liver, heart and result in depression or dementia. The first thing we must do is reduce the harm your drinking is doing. The best way to do cut down is to limit the number of drinks you have and write the total in a diary. Drink light beer or space your drinking with soft drinks. Try to have two alcohol free days each week and limit your drinking to two drinks on other days. Come back and see me in a fortnight and show me the diary. I expect you to have good and bad days, this can be hard and scary at first but stick with it and come and see me in two weeks. Once we get started there are other ways that I can help (motivational interviewing).

F11: Drug abuse/dependence:
Your drug use is a serious problem (codeine, sedatives or marijuana; if other drugs refer patient to drug and alcohol service) and we have already discussed that it is making problems at work and with the family. You need to decide to quit. The best way to do this is to keep a diary of your drug use and try to gradually reduce it. Why don't you come back in a week with the diary and we can then review when you used and why you used at that time. Once you have decided to quit I can help further (motivational interviewing).

F20: Chronic Psychosis in relapse.
We've talked about how difficult it is for you to concentrate or to motivate yourself to do things, and that you are still hearing voices and have ideas that are different to those of other people. Regular medication can help control your symptoms. New drugs like risperidone are easier to take than the older medications. I will begin you on a low dose of risperidone and I want you to come back and see me in a week. At that time I'd like to see you with your family or others you live with when we can discuss other strategies for managing your symptoms like the problem solving technique and social skills training.

F23: Acute Psychotic Disorder
You've said that you can't think clearly, that you are having strange experiences and that all this is very frightening. There are a number of possible reasons for this change in you and they will need to be investigated. I will refer you to a specialist who will advise about the diagnosis and treatment. We could arrange for you to go to hospital but it would be better if we can manage this with you staying at home. In the meantime I would like you to take some medication that will lessen the strange experiences and the fear. Until you see the specialist I'd like to see you most days to make sure you are progressing properly. [make an appointment with a private psychiatrist or with the community mental health centre, or discuss the case with the registrar on duty at the inpatient unit]

F31: Bipolar Disorder
You've said that you are very energetic and active, very elated and irritable, not your usual self at all. I think you have an illness called hypomania and that if not treated you are likely to spend all your money, and upset your family and friends, and generally do yourself no good. (If recurrent episode) I think you should go back on your medication and hopefully will not need to go back to hospital. I'd like to organize an appointment with the specialist that looked after you last time. (If first episode) I'd like to get a specialist opinion and while we wait for that I'd like you to take medication that should help your mood and energy become more normal. I'd like to speak to your family about your condition. Later I'd like to teach you and the family problem solving techniques to lessen difficulties. (If in depressive phase treat for Depression).

F32 Depression:
You've said that your mood is low, you've lost interest in things and there have been other changes as well. These symptoms have lasted for some time now and are not really explained by what has happened to you, even though you think that you are in some way to blame. I think you are suffering from Major Depressive Disorder. Untreated, it is likely to last for months, during which time you might damage your job prospects and your friendships. (If depression is moderate or severe say) I think you need treatment with an antidepressant medication. Once you are started on the medication I will teach you psychological ways (activity scheduling, problem solving, cognitive therapy) to hasten your recovery and help you remain well. I'd like to see you in a few days and it would be best if your wife/husband/friend came with you so that we can all work together to get you well. Alternatively I could refer you to a specialist. Which would you prefer?

F40 Social Phobia:
For years you've become very anxious when in company, in case others notice that you're anxious, or you say or do the wrong thing. The risk in your mind is that that they will think you are weak or incompetent and this is the reason you avoid such situations. This condition is called social phobia and without treatment it tends to persist, because each time you avoid a situation, the relief you feel strengthens the fear of that and similar situations. Antidepressant medication will lessen your anxiety and make it easier to enter situations and this might suit you. I could teach you to reduce your anxiety using the controlled breathing technique, how to view your reactions to situations more clearly (cognitive therapy), and how to master feared situations by confronting them in a planned way (graded exposure). Alternatively I could refer you to a specialist for treatment. Which would you prefer?

F41 Panic Disorder/Agoraphobia
You have sudden attacks of fear in which your heart beats fast, you can't breathe and you have other physical symptoms of anxiety. In consequence you fear you might have a heart attack, collapse and die during one of the attacks. You have begun to avoid situations in which escape wouldn't be possible or help couldn't get to you if an attack occurred. The condition is called panic disorder with agoraphobia. Without treatment it tends to persist, because each time you avoid a situation the relief you feel strengthens the fear of that and similar situations. I could teach you how to control some of your anxiety using the slow breathing technique, how to challenge worrying thoughts using cognitive therapy and how to master feared situations by confronting them in a planned way (graded exposure). Antidepressant medication will also lessen your panics and make it easier to enter situations Alternatively I could refer you to a specialist for treatment. Which would you prefer?

F40.2 Specific Phobia
Many people have excessive fears of snakes, poisonous insects, heights, closed places, dogs and still water. Mostly these fears have been present since childhood and mostly people learn to avoid such situations. This avoidance reinforces the phobia. If your phobia is interfering with your life and activities too much I could teach you how to confront and master your fear using graded exposure.

F41.1 Generalized Anxiety Disorder
You're worried about a physical symptom that as far as I can see is not evidence of a serious illness. You've mentioned that you've had persistent and uncontrollable worry over everyday things for months. Being on edge and physically tense is wearing you out. You said that you've been like this, on and off, for much of your life, but that this spell has gone on too long. Your condition is called Generalized Anxiety Disorder and tends to persist. You might choose to learn some psychological strategies like slow breathing and problem solving and relaxation to control your worry and tension. I could treat you with an antidepressant drug that would reduce your worry. We could do both, so that after you stop the medication you will still have strategies to manage. Alternatively I could refer you to a specialist. Which would you prefer?

F41.2 Mixed Anxiety and Depression
You've said that your mood is low, you've lost interest in things and that you are worried and anxious all the time. These symptoms have lasted for some time now and are not really explained by what has happened to you even though you think that you are in some way to blame. I think you are suffering from Mixed Anxiety and Depression. Untreated, it is likely to last for months, during which time you might damage your job prospects and your friendships. I think you need treatment with an antidepressant medication and with psychological strategies. Once you are started on the medication I will teach you psychological ways (activity scheduling, problem solving, cognitive therapy) to hasten your recovery and help you remain well. I'd like to see you in a few days and it would be best if your wife/husband/friend came with you so that we can all work together to get you well. Alternatively I could refer you to a specialist. Which would you prefer?

F42.2 Obsessive Compulsive Disorder
You've told me that fearful thoughts of harm to you or your loved ones keep entering your mind no matter how hard you try and resist. To control your fears, you have been checking or washing repeatedly to the point that the obsessions and the compulsions interfere with your life to the point that your life seems dominated by the disorder. Antidepressant medication will lessen the power of the obsessions so that they are easier to resist. Additionally I could show you how to manage the compulsions in a planned way (graded exposure and response prevention) so that the strength of the obsessions lessens and you become well. Alternatively I could refer you to a specialist for treatment. Which would you prefer?.

F43.2 Adjustment Disorder
You've been through a tough time. You are overwhelmed by what's happened to you. It's been difficult to cope and you've been feeling sad and anxious. Unfortunately medication that calms your nerves takes away your ability to manage. If we do nothing, your distress will pass, but I'd like to use this opportunity to teach you ways of coping that hasten recovery and make you more able to cope in the future. They are Stress Management/ Structured Problem Solving . Here is a handout. Read this and come back tomorrow when we can go through it.

F44 Dissociative or conversion disorder
Sometimes stress or shock can result in physical symptoms. I do not think that your symptoms are due to a serious physical illness. They could be the result of stress. I want you to go home, go to bed and rest, then come back and see me. I'll review your symptoms and then teach you some ways to cope with stress that are less likely to result in symptoms (Structured problem solving, progressive muscular relaxation, communication training).

F45 Unexplained somatic complaints
You've told me that your symptoms trouble you a lot but that no one can find a cause. I can find no evidence of serious illness but your symptoms are real to you and do interfere with your life. While your condition is not common we can help you manage better. We have seen others do well. Given that we don't understand the cause I suggest that you learn better ways of coping with stress (structured problem solving), ways to relax (progressive muscle relaxation) and ways to begin to enjoy life again, despite the symptoms (activity scheduling). Alternatively I could refer you to a specialist who could teach you these things.

F48 Neurasthenia
You've been tired and easily fatigued for some time now. Investigations have not shown a specific medical cause that we can treat. However, many people with this problem have had great benefit from straight forward things like getting your pain under control, sleeping properly and then gradually beginning to exercise (activity scheduling). Make an appointment for tomorrow when I can spend time with you and we can plan it out.

F50 Eating Disorders
You've described problems with dieting, binge eating and vomiting. None of it makes you happy with yourself, nor are these effective ways of managing your weight. Unless we do something it will just go on and there is a real risk that you'll get physically sick and depressed. Lets look at healthy ways of eating without weight gain. I'll need you to keep a food diary and note the events that test your resolve. Then I'll teach you some psychological strategies to help you feel better about yourself and be in charge of your problems. (structured problem solving, cognitive therapy, communication training).

F51 Sleep Problems
You have told me that you are having trouble sleeping. I do not think that it is because of some disease or condition, only that your sleep habits have got out of order. Sleeping pills do work, but only for a few weeks and you are likely to become dependent on them. So we need to put your sleep habits right. Here is a handout about sleep. I want you to fill in the sleep chart every day, read all about sleep and follow the rules for good sleep on the last page of the handout. I'd like to see you in a week to check progress.

F52 Sexual Disorders in Men
You've described sexual difficulties that occur when you are with a partner. They don't occur when you are on your own. We will need to make sure there is no physical cause. There are a number of things I can do. Firstly there is medication to improve your erection but we will also need to work on your confidence and your relationship (communication training, graded exposure). Alternatively I could refer you to a specialist.

F52 Sexual Disorders in Women
You've described sexual difficulties that occur when you are with a partner. We will need to make sure there is no physical cause. There are a number of psychological strategies that might help. We will need to work on your confidence and your relationship (communication training, progressive muscle relaxation, graded exposure). Alternatively I could refer you to a specialist.

F90 Hyperkinetic (Attention deficit) disorder
You have said that your child can't sit still, is easily distracted and is impulsive and disrupts others. From what we have seen in the consulting room I agree. He could have attention deficit disorder. This behaviour is likely to result in him having difficulty at school and in some cases becoming identified as bad or uncontrollable. There are two arms to treatment, the use of medication to increase his attention span, and the development of a settled home environment that lessens the triggers to his disruptive behaviour. Medication can only be prescribed by a specialist but you and I could work in partnership with specialist on how to change things at home (parent management training) and at school. You might choose to see a specialist alone.

F91Conduct Disorder
You have told me how worried you are about your child's aggressiveness, bullying, cruelty, stealing and lying. You're worried that he might get into trouble with the law. Some children outgrow this phase but many do not and continue to have trouble as young adults. I will teach you two strategies, parent management training and structured problem solving, to help you manage your child better. Alternatively I could refer you to a specialist. Which would you prefer?

F98 Enuresis
Your child, even though now in school, is still wetting the bed most nights. This is called enuresis. It is time to do something about it. I will prescribe a low dose of an antidepressant drug and this will help the child to be dry. Your child should take responsibility for managing his bedding when it is wet, and should keep a list of dry nights on a calendar. You should reward progression towards being dry. If necessary we can get an alarm system to wake him the moment he begins to urinate. He should do well.

Z63 Bereavement and other stressors
You have told me how difficult it is since your (spouse/child/parent died)(since the trauma occurred). While recovery is the rule, there are some ways of coping with such events. Here is an information sheet (Management of Mental Disorders: managing loss or bereavement / Management of Mental Disorders: psychological responses to stress: what to expect and what to do), read it and discuss it with friends or family. Come back in a few days to tell me how you are going to put the advice into action.

References and recommended reading:
1. Craighead, W. E., Miklowitz, D. J., Vajk, D. J., & Frank, E. (1998). Psychosocial Treatments for Bipolar Disorder. In P. E. Nathan & J. M. Gorman (Eds). A Guide to Treatments that Work. New York: Oxford University Press.
2. Lampe, L. (1996). A Management Approach to Anxiety. Australian Family Physician, 25(10), 1561-1567.

Motivational interviewing

What is it?
Motivational interviewing (MI) was originally developed by specialists working with problem drinkers (see Miller, 1991). MI is a useful technique to use with people who are initially ambivalent or reluctant to change, particularly when the problematic behaviour is rewarding (e.g. smoking, drinking excessively). This technique avoids confronting the client (e.g., disagreeing, emphasising evidence of impairment, arguing), as this is associated with higher levels of resistance and lowers the likelihood of behaviour change (Miller, Benefield, & Tonigan, 1993). Instead, reasons for concern and change are elicited from the patient. These are then explored with the patient in a supportive manner. The goal is to highlight any discrepancies between present behavior and desired goals, as there is evidence to indicate that this can trigger behaviour change (Miller & Rollnick, 1991). Miller and Rollnick (1991) outline five key elements involved in MI:

1. Express empathy.
2. Develop discrepancy.
3. Avoid argumentation.
4. Roll with resistance.
5. Support self-efficacy.

Does it work?
Studies have shown that the behaviour of the therapist has an influence on treatment outcome (e.g., Miller , Benefield, & Tonian, 1993). Such studies lend support to one of the core ideas behind MI, that is, the more you confront the patient about their problem, the more they will engage in the problem behaviour (e.g., drinking). MI advocates that the clinician will be most effective if he or she adopts an empathic approach and works with the patient to enhance motivation for change. Thus, while the evidence is promising, further empirical support is needed, particularly, as there is growing interest in applying this technique to a wide variety of problem behaviours (see Emmons & Rollnick, 2001).

How do you do it?
Miller and Rollnick (1991) have outlined the process of motivational interviewing in detail. It is recommended that the following summary is supplemented with further detailed reading.

1. The first step is to build the patient's motivation for change. It is assumed that initially, the patient will be ambivalent about changing and this is described as the contemplation' or 'precontemplation' stage. Prochaska and DiClemente (1982) have described a six stages of change model which serves as a guide for understanding how and why people change. The six stages are pre-contemplation, contemplation, determination, action, maintenance and permanent exit.

2. There are five strategies that are recommended for building the patient's motivation for change. These are:

(i) Ask open-ended questions. This is important first step in order to establish rapport between the patient and yourself. Some examples include, 'I'd like to understand how you see things. What's brought you here? What's been the problem?
(ii) Listen reflectively. This can be explained as a way of 'checking', rather than 'assuming' that you now what the patient means.
(iii) Affirm. This can take the form of compliments or statements that indicate and appreciation and understanding of the patient's situation. For example, 'I appreciate how hard it must have been for you to decide to come here'.
(iv) Summarise. Use summary statements to link information that has been provided by the patient, to summarise ambivalence (e.g., 'it sounds like you are torn two ways…..'), and to check that you have understood him or her correctly.
(v) Elicit self-motivational statements. The goal is to facilitate the patient's ability to decide upon their own arguments for change, rather than providing the reasons for them. Ideally, you want the patient to arrive at statements such as: 'this is serious…, I've got to do something about this…, I'm going to overcome this problem…'. ```````

3. The next major step is to ascertain how ready the patient is for change. This can be done by exploring the advantages and disadvantages of the present problematic behaviour. The aim at the end of this process is for the patient to realise that the costs of their problem behaviour outweigh any benefits. Formal assessment methods can also be used to assist with this process. Feedback about the results on these measures can be used to enhance motivation and further illustrate any discrepancies between current and desired behaviour.
For example, Miller and Rollnick (1991) recommend that for drinking problems, the patient is provided with their scores on a relevant measure and an explanation about their score in relation to the population (or other relevant comparison data). It is best to avoid any 'scare tactics' when presenting this information and it can be prefaced with, 'this may or may not concern you…'. Eliciting the patient's reactions to this information is also useful, 'is this what you expected…', how do you feel about this…'.

4. It is suggested that at the end of this stage of assessment a summary of what has been discussed is provided. This should include (Miller & Rollnick, 1991, p. 99):

(i) the risks and problems that have emerged from assessment findings;
(ii) the patient's own reactions to the feedback, including any self-motivational statements that have been made; and
(iii) an invititation for the client to add or correct the summary.

5. The next phase is to continue to strengthen the commitment to change and to negotiate a treatment plan with the patient.

References and recommended reading:
1. Emmons, K. M. & Rollnick, S. (2001). Motivational interviewing in health care settings. Opportunities and limitations. American Journal of Preventive Medicine, 20(1), 68-74.
2. Miller, W., Benefield, R., & Tonigan, S. (1993). Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 4550-61.
3. Miller, W. R. & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.

Cognitive- Behavioural Therapy (CBT)

What is it?
Cognitive behavioural therapy (CBT) is well established as an effective treatment for a range of disorders (e.g., anxiety, affective disorders) (see Nathan & Gorman, 1998). As the name suggests, CBT utilises a combination of behavioural and cognitive techniques to target a patient's symptoms. The focus is on teaching patient's how to control their symptoms, correct faulty thinking patterns and manage their own disorder. Ideally, at the end of treatment, patients should be able to use the strategies they have been taught to deal with any future problems and possible return of symptoms. The content of CBT should be determined according to need and the duration should be time limited.

Summary of the components of CBT detailed in this document

1. Cognitive interventions	Cognitive therapy
2. Behavioural interventions	Behaviour modification
	Exposure techniques
	Activity scheduling

Does it work?
There are a number of studies demonstrating that CBT is effective for a variety of disorders (e.g., depression, anxiety, schizophrenia, eating disorders) (see Enright, 1997 for a review). Further, in randomised placebo controlled trials, CBT has been found to be of comparable effectiveness to appropriate drug therapy (Andrews, 1993). The effects of CBT have also been found to be relatively long lasting. Treatment gains have been maintained at one-year follow-up (e.g., Ladouceur, 2000) and beyond (e.g., Fava et al., 2001)

How do you do it?
The techniques outlined below are designed to be used in collaboration with the patient. See below for an explanation of the main techniques and how to do them.

References and recommended reading:
1. Andrews, G. (1993). The essential psychotherapies. British Journal of Psychiatry, 162, 447-51.
2. Enright, S. J. (1997). Fortnightly review: Cognitive behaviour therapy-clinical applications. British Medical Journal, 314, 1811-1816.
3. Fava, G.A., Bartolucci, G., Rafanelli, C., Mangelli, L. (2001) Cognitive-behavioral management of patients with bipolar disorder who relapsed while on lithium prophylaxis. Journal of Clinical Psychiatry, 62(7), 556-9.
4. Ladouceur, R., Dugas, M. J., Freeston, M. H., Leger, E., Gagnon, E., & Thibodeau, N. (2000). Efficacy of a cognitive-behavioural treatment for generalised anxiety disorder: Evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology, 68, 957-964.
5. Nathan, P. E., Gorman, J. M. (Eds.). (1998). A guide to treatments that work. New York: Oxford University Press.

Cognitive interventions

Cognitive therapy

What is it?
Beck (1979) describes cognitive therapy as 'an active, directive, time-limited, structured approach used to treat a variety of psychiatric disorders (for example, depression, anxiety, phobias, pain problems, etc)' (p. 3). Cognitive therapy is based on the idea that the way a person interprets or appraises a situation is based his or her past experiences, and this focus influences how he or she thinks and subsequently feels. When a person feels threatened they selectively pay attention to what they fear and so are limited in their ability to evaluate the whole situation rationally. The idea behind cognitive therapy is that modifying the way a person thinks, will change the way he or she will interpret a situation, which should lead to a subsequent change in behaviour. For example, a person with depression will often have a number of negative thoughts, which is a classic 'cognitive symptom'. Although treating some of the symptoms of depression using behavioural techniques (e.g., activity scheduling) will be effective, it is also important to focus on this cognitive symptom directly.

The A-B-C model developed by Ellis (1975) is often used to explain the influence of the way we think, on the way we feel and behave.

It is commonly assumed that A leads directly to C. However, in most cases, it is a person's reaction or thoughts in response to an event, B, that influences how he or she feels. Consider the following example.

Mary presents for a medical certificate saying she fears going to work. She recently began a new job. She has looked forward to starting her new role for some time and is keen to make a good impression on her colleagues. Mary goes out of her way to be friendly toward everyone but finds that her new colleagues do not make the same effort and sometimes even ignore her. This makes Mary feel like she is worthless and that there must be something wrong with her. To make matters worse her boss is very inpatient and yells at her for no reason. Mary loses her motivation to go to work and starts to think that she must be 'boring', that people think she is stupid,(Further enquiry makes it clear that she feels they think incompetent and not worth bothering with. Mary starts to feel down and gets quite anxious before going to work.xxxadd D&E steps

Clearly, this was an unpleasant event for Mary to experience when she started her new job. While, it is not unreasonable to feel upset by her boss and colleagues reactions, Mary's reaction went beyond this.

Referring back to the ABC model for Mary:
A = Activating event = being ignored by colleagues and boss yelling at her.
B = Belief or reaction to A = Mary says to herself that she is boring, stupid, incompetent and not worth bothering with.
C = Emotional consequences = feeling very down, upset, and anxious.

As illustrated above, our beliefs and what we say to ourselves (i.e., 'self-talk'), have a very strong influence on how we feel. Thus, the aim of cognitive therapy is to teach patients how to modify their beliefs (B) about an event, in order to change their emotional reaction (C).

The next stage, often referred to as D in this model, is where the patient learns to 'challenge' their negative thoughts and substitute in more rational beliefs. The end result is E, a new emotional effect or consequence.

To summarise:

Does it work?
Cognitive therapy has been found to be an effective component of treatment for a variety of disorders. For example, cognitive therapy is at least as effective as drugs in the treatment of unipolar depression (e.g., Hollon, Shelton & Loosen, 1991), panic disorder (e.g., Clark, et al., 1994), and generalised anxiety disorder (Power et al, 1990). Further, patients who receive cognitive therapy are also less likely to relapse following treatment termination (Teasdale et al., 2001)

How do you do it?
Typically, cognitive therapy is not used alone but in conjunction with other techniques. These techniques will be guided according to the disorder that is being treated (e.g., when treating anxiety, exposure may be used concurrently) and cognitive therapy should be tailored accordingly. Cognitive therapy consists of several key components and specific techniques are available to guide therapy. These are presented below in a simplified form, but is recommended that the reader refer to the primary texts to gain a full understanding. It is also important to note that this form of treatment is best provided by a clinician specifically trained in this style of therapy, and the following guide should be supplemented by specialist training

Key components of cognitive therapy

1. Explain the A-B-C model
2. Identify and elicit negative automatic thoughts (NAT's) and dysfunctional beliefs
3. Test these NAT's by generating and assessing the evidence for and against
4. Challenge NAT's and dysfunctional beliefs
5. Generate more rational and realistic counter-statements

1. Explain the rationale behind cognitive therapy and use the A-B-C model to guide your explanation.
2. One term that is referred to frequently in cognitive therapy is 'negative automatic thought' (NAT). As the name implies, these are negative thoughts, occurring automatically in response to a situation or event. These thoughts can occur either consciously or unconsciously. NAT's are often the focus of cognitive therapy because they are strongly believed by the person and these thoughts exert a powerful influence on behaviour and interpretations of events. For example, a man who reports anxiety when speaking in public may report the NAT that 'everyone will think he is stupid', which leads him to avoid such situations. A depressed woman might typically report the NAT 'everyone hates me' and so withdraw from the people around her.
3. It is useful to ask the patient to monitor his or her thoughts is relation to certain situations which occur over the coming week. This can be done in a format similar to the example below.

Example of thought monitoring form

4. When the patient returns with examples of their thoughts from the previous week(s) you can start to work together to test the evidence for and against the thoughts. The aim of this process is not to tell the patient what to think, but to work collaboratively and teach the patient how to challenge their thoughts in a more realistic manner. You can start off by eliciting more details about the reported situations and asking the patient to report what thoughts were going through their head at the time.
5. It is important to determine at this stage whether the thoughts the patient is reporting are rational or whether the thoughts are irrational, and reflect some of the common thinking errors. These thinking errors include:

• All or none thinking: some people see things in black or white categories. This means that they usually see things as being only one extreme or the other - black or white - no shades of grey. For example, 'I used to be so confident, but now I am hopeless at everything'.
  
  
• Overgeneralization: people who engage in this style of thinking tend to draw conclusions on the basis of one or more isolated events, and then apply this to other related and unrelated areas of their life. For example, if someone fails a test they might think, 'I am hopeless at everything I do'.
  
  
• Selective abstraction (filtering): this happens when a person focuses on a specific detail of an event and takes this out of context. The person will tend to ignore other important features of the situation and make unwarranted conclusions. For example, when the person is talking to someone they might notice them glance away momentarily and conclude, 'they think I'm boring'.

• Discounting or disqualifying the positive: some people tend to reject successful experiences or positive events by generating a reason why it does not count. For example, if someone manages to catch a train all the way to work, they might discount the event by saying, 'it wasn't full today, so it didn't count'
  
  
• Jumping to conclusions: sometimes people tend to draw a conclusion even when there are no facts to support it. A good example, is when people 'mind read' or think they know what another person is thinking. For example, they might think 'my friend thinks I'm not worth bothering with', even though the friend has not said this.
  
  
• Magnification or minimization: this is when people assign too much or too little importance to an event. For example, a person who makes one mistake in a test might think, 'this is a total disaster, I'm going to fail my course and get kicked out of the university'.
  
  
• Personalisaton: this occurs when a person blames things on themselves when there is no reason for taking part or all of the blame. For example, 'I always bring bad luck'.

It can be useful to point these errors out to the patient to make them more aware of when they are being unrealistic.

6. As discussed, you need to start working with the patient to generate evidence for thoughts. This can be done by asking a series of questions. You can start by generating evidence for the thought being true and then look at the evidence against the thought being true. This can be done by asking, 'what is the evidence for the thought being true?' and 'what is the evidence against this thought being true?'. It is useful to do this in a quite a structured manner and to write it down when you first attempt this technique with the patient.

Other useful questions for eliciting information are: 'what is actually true about this thought/situation?, what is not true about this situation?, are there facts that you are forgetting or not acknowledging?.

7. Then you need to work with the patient to come up with more realistic or rational interpretations of their thoughts. This can be done by asking questions such as, 'what's a more reasonable and helpful way of looking at this situation?, what could you tell yourself next time you have this thought?, what would a different person say about the thought?, what advice would you give someone else with this thought?'. These should also be written down for the patient. Most clinicians find that patients learn from carrying out and evaluating tasks as homework

8. As you might expect, this is a time-consuming process. The patient will not necessarily believe their rational first immediately. Ask them to rate how much they believe the thought before and after you begin examining other rational alternatives. This should give you an indication of shifts in the patient's thinking and you should continue to work through this process until shifts in thinking, small or large, occur.

References and recommended reading:
1. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.
2. Beck, A. T., Rush, A. J., Shaw, B. F. & Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford Press.
3. Clark, D.M., Salkovskis, P. M., Hackman, A., Middleton, H., Anastasiades, P., & Gelder, M. (1994). A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British Journal of Psychiatry, 164:759-69.
4. Ellis, A., & Harper, R. A. (1975). A new guide to rational living. California: Wilshire Book Co.
5. Hollon, S. D., Shelton, R. C., & Loosen, P. T. (1991). Cognitive therapy and pharmacotherapy for depression. Journal of Consulting and Clinical Psychology, 59, 88-99.
6. Power, K. G., Simpson, R. J., Swanson, V., Wallace, L.A., Feistner, A. T. C., & Sharp, D. (1990). A controlled comparison of cognitive-behaviour therpay, diazepam, and placebo, alone and in combination, for the treatment of generalized anxiety. Journal of Anxiety Disorders, 4, 267-292.
7. Teasdale, J. D.; Scott, J.; Moore, R. G.; Hayhurst, H.; Pope, M.; Paykel, E. S. (2001) How does cognitive therapy prevent relapse in residual depression? Evidence from a controlled trial. . Journal of Consulting & Clinical Psychology, 69(3), 347-357.

Behaviour modification

Behavioural Assessment? (initial assessment, monitoring progress, modifying treatment)

What are the behaviour therapy techniques?
These techniques are used to decrease problem or dysfunctional behaviour (usually excesses) or to increase or learn desirable or functional behaviour. It is particularly effective for the treatment of externalizing disorders and for developing prosocial and basic living skills in children or in adults with an intellectual handicap.

Behaviour modification starts with a thorough behavioural analysis, which involves specifying and measuring the behaviours to be altered, and identifying the antecedents and consequences controlling these behaviours. This analysis is followed by a systematic program which may include altering the stimuli triggering the unwanted behaviour, shaping up new adaptive (competing) behaviour, and contingency management (using reinforcers for increasing desirable behaviour and costs to decrease the unwanted/dysfunctional behaviour).

After changing particular behaviours, techniques for generalization and maintenance of gains are discussed, along with relapse prevention.

Does it work?
Behavioural interventions are an important component of treatment for a variety of disorders. The specific evidence is discussed in relation to the techniques outlined below.

How do you do it?
Some of the key behavioural interventions and how you do them are outlined below.

Exposure techniques

What is it?

Exposure techniques are used for all anxiety disorders, particularly the phobias. Essentially, exposure involves confronting the feared situation/event/activity so that the fear decreases, or ideally, extinguishes.

Graded exposure is the most commonly used exposure technique. It involves identifying a patient's fears, and constructing a hierarchy of the least to most feared situations. A graded approach is necessary because of the fear it provokes and few people would be willing to confront this immediately and directly when commencing treatment. Therefore, the individual enters the anxiety provoking situations in graded steps so that anxiety is evoked, but not overwhelmingly so. The individual is then instructed to stay in the situation until their anxiety decreases. By remaining in the situation until the fear subsides, the person learns that it is groundless.

Systematic desensitization is similar in that it involves exposure to a hierarchy of feared objects or situations (often in imagination) while using slow breathing, and/or other relaxation techniques, and cognitive coping self-statements to cope with the anxiety experienced. On exposure, the person is assisted to implement the learned relaxation techniques and use the coping self-statements until the fear subsides. Desensitisation is most often used when it is impossible to confront the fear (e.g., fear of flying) but few GPs will have the time or experience and should refer patients that need this to a Clinical Psychologist.

Does it work?
There are many studies of the use of graded exposure in simple and specific phobias and in agoraphobia with follow up studies showing that the benefit is long lasting (e.g., Munby & Johnston, 1980). Exposure is now used as a component of treatment in social phobia (with cognitive therapy) (Taylor, 1996), in obsessive compulsive disorder (with response prevention) (Abramowitz, 1997), in generalised anxiety disorder (with problem solving and relaxation) (Ladouceur, et. al, 2000) and in posttraumatic stress disorder with exposure both to the memories and to situations evoking the memories (Foa et al., 1991).

How do you do it?
Graded exposure in vivo.
1. It is important to provide a good rationale to the patient when you introduce graded exposure into treatment. The patient will usually find the idea of confronting feared situations quite daunting. Typically, these are situations the patient would have spent a great deal of time prior to treatment trying to avoid and so this will be an unpleasant task. Therefore, a good rationale is crucial before beginning any exposure tasks and if explained properly, the likelihood of the patient actually carrying out the exposure tasks and complying with treatment is increased.

For example,
'one way of overcoming fear provoking situations that you have avoided in the past is to confront these situations in a gradual manner. I know you get very anxious when X happens (e.g., you see a spider, you give a speech), so I'm not going to ask you to confront your most feared situation straight away. Instead, over the next few weeks, I will be asking you to do a number of tasks that will start off quite easy and get harder, until you are able to do X (most feared situation). While you may still find X difficult, every time you enter an anxiety-provoking situation, your fear should decrease (refer to specific everyday examples such as learning to drive). The more times you so this, the easier it will get, and eventually you will learn that nothing bad will happen to you. Eventually, you should be able to confront your feared situation without overwhelming anxiety'.

2. The next step is to develop an exposure hierarchy in collaboration with your patient. Ask the patient to write down all the situations/events/activities he or she avoids. Direct the patient to think of situations that range from :

• extreme anxiety 95-100/100 (where a large number indicates extreme distress in the situation) through to
• mild 10/100 (where a lower number indicates mild distress in the situation).

Feared situations are seldom simple, for example a person with agoraphobia might fear train travel because they are getting further from home (and help) but also fear crowded trains because escape would not be possible. While only the patient knows the detail of what they fear, the clinician must ensure that the exposure situations address the complexity of the fears.

3. Next decide upon approximately 10 situations (if the hierarchy is too small then opportunities for improvement is limited) which will be able to be implemented as part of the patient's exposure plan. When deciding on situations that are appropriate, try to choose scenes that are specific (e.g., 'catch bus from A to B at 9:00am Tuesday morning', rather than 'catch the bus') and detailed (e.g., 'have a conversation' is too vague).

4. Then help the patient organise the situations from least to most feared. This is not always an easy process. However, there are not set rules for guiding this process, just try to arrange the hierarchy in a logical, ascending order. It may be helpful to write the scenes on separate cards and spend some time arranging these.

5. Ensure that a range of situations have been included in the hierarchy and that there are no sudden jumps in the levels of distress. If there are, have the person add intermediate situations or modify one of their items (if necessary, intermediate steps can be added in once the patient begins undertaking exposure tasks).

6. The next step is encouraging the patient to begin exposure. Ask them to enter one of the easiest situations on their own and remain until anxiety is halved, then instruct the patient to repeat this until there is little associated anticipatory anxiety about entering the situation. While there is no exact timeframe for how long the patient should remain in the situation, ideally, the patient should be encouraged to stay in the situation for as long as he or she can tolerate (within reason). This should allow ample opportunity to learn that nothing bad will happen and that habituation to anxiety will occur. However, there are often practical constraints that need to be considered. Such constraints will often guide how long the exposure exercise will last. When a particular exposure exercise is brief (e.g., 'initiating a conversation with a stranger'), it should be repeated a number of times.

7. The patient should then move on to the next situation and repeat until less anxiety occurs.

8. The patient should do exposure at least three to four tasks per week and you should review progress weekly to ensure he or she is confronting their fears. Any success must be reinforced, even good effort at a task that was not successful is a reason for praise. Once mastery of a situation occurs patients will become pleased and proud and clinicians should reinforce this.

9. Motivation is often a problem, given the unpleasant nature of what you are asking the patient to do. At times, you will need to remind the patient of the rationale behind exposure and encourage him or her to continue to confront the feared situations until mastery is achieved.

Tips:

· ensure that the patient does exposure repeatedly - even if they feel they have conquered their fears
· within reason, allow the patient to determine the rate at which they progress through their hierarchy
· sometimes several smaller hierarchies might be more workable than one large hierarchy, if there are distinct situations that require attention (e.g., attending social gatherings)
· you can also explain exposure to the patient as a 'behavioural experiment' that can be used to test out their fears.For example, if a patient says 'everyone will laugh at me', then you can set an exposure task that will allow them to test out this belief
· if a patient is extremely anxious or resistant prior to an exposure task then you can:

- modify their hierarchy
- add more intermediate steps into the hierarchy
- encourage the patient to do the task with a friend or partner

· keep in mind that a patient's progression through their hierarchy will not always run smoothly. At different times and for various reasons (e.g., lack of motivation, a change in personal circumstances), they will experience setbacks and it will be necessary to remind him or her about the rationale for exposure and encourage persistence with the hierarchy.
· it may helpful if you ask the patient to keep a diary, so he or she can record their anxiety levels and any problems that were encountered.

Special Issues in Obsessive Compulsive Disorder (to be added)

Special issues in Bulimia (to be added)

Special Issues in the treatment of sexual disorders (to be added)

References and recommended reading:
1. Abramowitz, J. S. (1997). Effectiveness of psychological and pharmalogical treatments for obsessive-compulsive disorder: A quantitative review. Journal of Consulting and Clinical Psychology, 65, 44-52.
2. Andrews, G., Crino, R., Hunt, C., Lampe, L. & Page, A. (1994). The Treatment of Anxiety Disorders. Melbourne: Cambride University Press.
3. Andrews, G. & Hunt, C. (1998). Treatments that work in anxiety disorders. Medical Journal of Australia, 168, 628-634. 4. Foa, E. B.; Rothbaum, B. O.; Riggs, D. S.; Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting & Clinical Psychology, 59, 715-723.
5. Ladouceur, R., Dugas, M. J., Freeston, M. H., Leger, E., Gagnon, E., & Thibodeau, N. (2000). Efficacy of a cognitive-behavioural treatment for generalised anxiety disorder: Evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology, 68, 957-964.
6. Munby, J. & Johnston, D.W. (1980). Agoraphobia: long-term follow-up of behavioural treatment. British Journal of Psychiatry, 135, 418-27.
7. Taylor, S. (1996). Meta-analysis of cognitive behavioural treatments for social phobia. Journal of Behaviour Therapy and Experimental Psychiatry, 27, 1-9.
8. Treatment Protocol Project (2000). Management of Mental Disorders (Third Edition). Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse.

Activity scheduling

This technique is mainly used to assist patients with depression. Activity scheduling is a useful strategy to teach patients who have both lost interest in doing things they enjoy and who find it difficult to do basic daily tasks. It is particularly important to increase pleasurable activities when people feel depressed, as they feel less inclined to engage in activities that are a source of pleasure and satisfaction. Similarly, when people are not involving themselves in activities they consider pleasant, this can make them feel depressed. This creates a vicious cycle and in order to break this pattern of inactivity patients need to learn how to keep active when they feel down. Activity scheduling is a behavioural technique designed to mobilise the patient and to increase the range and frequency of pleasant activities engaged in. The overall aim is to teach patients how to increase their activities in a structured and organised manner, thereby increasing mood. Activity is the key, and mastery of tasks, pleasant activities, or exercise should be reinforced.

Does it work?
Activity scheduling is an effective behavioural treatment for depression (see Lewinsohn & Gotlib, 1995).

How do you do it?
1. If a patient is not engaging in their usual activities, both routine (e.g., household duties) and pleasant (e.g., going to the movies), then it will be important to explain to the patient why they need to continue doing these activities. For example, 'you've told me that you no longer have the energy or motivation to do what you need to do and you have stopped doing things you enjoy. People often don't feel motivated when they are feeling down and sometimes stop doing the things they need to do and also stop doing the things they enjoy. It is important that you don't stop doing these things as the less you do the worse you will feel, and the worse you feel the less you will do.'

2. Ask the patient to tell you what things they are doing now and write these down. Then, ask the patient to rate their sense of achievement and how much pleasure they derive from performing these activities (on a scale from 0 to 6, where 0 = no pleasure or sense of achievement, 6 = high pleasure and sense of achievement).

3. The next step is to ask the patient to list all the things they should be doing but are not doing at the moment (e.g., grocery shopping). Then ask the patient to list at least ten things they would like to be doing and used to enjoy (e.g., meeting a friend for coffee, for further suggestions refer to 'Pleasant things to do', Management of Mental Disorders (2000), page 225).

4. If possible, activities should be arranged hierarchically - easiest to hardest - and each week, beginning with the easiest items, one to two activities will be chosen. Where necessary, complex activities (e.g., starting a course) should be broken down into smaller steps.

5. Discuss with the patient that it is important to try and achieve a balance between pleasurable activities and activities that are not pleasant but must be done.

6. With the patient, show them how to plan their activities in a structured manner. You can do this by going through their day hour by hour for the coming week or use the handout in Management of Mental Disorders (2000), on page 223-224.

7. Make sure you start off slowly and only schedule 1-2 pleasant activities in the first week. Do not try and fill every hour of the day. Even if the patient only does one pleasant activity during the week, this is better than doing none at all and will help give the patient a sense of mastery. You can increase the number and range of activities in the coming weeks. Don't forget to remind the patient to rate their sense of pleasure (P) and achievement (A) after completing the activity.

8. Ask the patient to record any other activities that occur and were not pre-planned. Ask them to rate their (P) and (A) for these too.

9. Remind the patient to bring their activity schedule to their next appointment. Review what went well and what did not go so well. Provide encouragement and try to build on what was achieved the previous week.

10. Encourage the patient to continue planning their activities until they resume their normal routine.

Sample Activity Schedule

Date: 1st March

Rating scale for sense of pleasure (P) and sense of achievement (A)

Tips:

• encourage patient to set aside time to plan their day (e.g., the night before)
• suggest that the patient start the day with activity that will provide both pleasure and achievement
• explain how exercise has been shown to help alleviate depressed mood (e.g., Lane & Lovejoy, 2001) and try to encourage the patient to make time in their day for this activity
• encourage the patient to be flexible - reschedule activities as needed and add other activities as they occur.
• aim for quality not quantity (e.g., 15 minutes of walking is better than aiming for a 1 hour run).

References and recommended reading:
1. Lewinsohn, P. M. & Gotlib, I. H. (1995). Behavioral theory and treatment of depression. In E. E. Becker & W. R. Leber (Eds.), Handbook of depression (pp. 352-375). New York: Guilford Press.
2. Lewinsohn, P. M., Munoz, R. F., Youngren, M., & Zeiss, A. M. (1978). Control Your Depression. New York: Prentice Hall Press.
3. Lane, A. M. & Lovejoy, D. J. (2001). The effects of exercise on mood changes: the moderating effect of depressed mood. Journal of Sports Medicine & Physical Fitness. 41(4):539-45.
4. Tanner, S. & Ball, J. (2000). Beating the Blues. A Self-Help Approach to Overcoming Depression. Southwood Press.
5. Treatment Protocol Project (2000). Management of Mental Disorders (Third Edition). Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse.

Relaxation strategies

What is it?

Relaxation is not a panacea and is seldom used on its own. There are a number of relaxation techniques, including guided imagery, controlled breathing, progressive muscle and isometric relaxation. Relaxation involves voluntarily releasing tension and reducing arousal of the central nervous system. Arousal may produce hyperventilation and so learning to breathe more slowly in a controlled manner counteracts this effect. Muscles also become tense when someone is anxious, so it is important to teach patients to develop an awareness of excessive muscle tension and what situations produce it. This can be taught through a series of exercises where the patient is instructed to progressively tense and then relax the muscles throughout the body. This procedure needs to be taught by a skilled practitioner and practised for a period of time before it can be effectively implemented in anxiety-provoking situations. Isometric relaxation is an abbreviated form of muscle relaxation that can be quickly invoked in anxiety-provoking situations. Guided imagery can assist with various forms of relaxation by providing a script and images of peaceful surroundings

Does it work?
While relaxation strategies are often considered to be an effective component of treatment for a variety of disorders (e.g., social phobia, panic attacks), there is no specific evidence to suggest that relaxation is essential. Thus, relaxation is most effective when used as a one component of treatment, rather than as treatment itself (Barlow et al., 1998). Typically, relaxation strategies are included in the early stages of treatment as they are a skill that can be taught easily to the patient, can provide a sense of control over anxiety symptoms and impart a sense of mastery in the early stages of treatment. Some patients are afraid that being relaxed might lead to loss of control and could lead to panic. They will do better if they use PMR and progress very gradually. Supervision is essential.

How do you do it?
Progressive muscle relaxation (PMR):
1. As with any technique, explain the rationale for PMR to the patient:

'today I will be teaching you a relaxation technique that, if practiced regularly, will help you feel less uptight and less tense. When you feel anxious and worried you tend to experience tension in various parts of your body. For example, many people feel tension in their neck and shoulders, others in their back or jaw, and some in their head or around their eyes. The idea behind progressive muscle relaxation is to teach you how to become more aware of when and where you feel tension in your body. To teach you this, I will be asking you to moderately tense the muscles in your body, one by one, starting with your hands and moving down to your feet. Once you've tensed a particular muscle, and held the tension for about 7-10 seconds, I will then ask you to relax and allow the muscle to go limp for about 15-20 seconds. This will allow you to experience a sense of relaxation before we move on.'
Answer any questions and provide more details as necessary.

2. Ask the patient to get comfortable in the chair and clear his or her mind of any worries or thoughts. Explain that clearing the mind may not happen readily at first, but it will become easier with practice. Some people find it useful to think calming expressions to themselves when using this technique such as: 'relax', 'let go of any tension', 'be calm'.

3. The patient should then practice the slow breathing method for about a minute. 'Now I would like you to breathe in for 3 seconds, 1 - 2 - 3, and out for 3 seconds, 1 - 2 - 3.' You can also ask them to imagine that the tension is flowing out of their body with each breath out.

4. Ask the patient to continue to breathe slowly in and out, and to curl their hands into a fist. Let them hold the tension for 7-10 seconds, and then relax the muscle. You may ask them to notice the looseness in their hand now it is relaxed and to contrast this with the tension just felt in this muscle. Also, make sure that the patient is tensing their muscles moderately and that he or she is not experiencing any pain. Further, when letting go of the tension the patient should let go instantly and feel the muscle go immediately limp.

5. Continue to instruct the patient to tense and relax his or her muscles in the following order:

• Lower arms - bend your hand down at the wrist, as though you were trying to touch the underside of your arm, then relax.
• Upper arms - tighten your biceps by bending your arm at the elbow, then relax.
• Shoulders - lift your shoulders up as if trying to touch your ears with them, then relax.
• Neck - stretch your neck gently to the left, then forward, then to the right, then to the back in a slow rolling motion, then relax.
• Forehead and scalp - raise your eyebrows, then relax.
• Eyes - screw up your eyes, then relax.
• Jaw - clench your teeth (just to tighten the muscles), then relax.
• Tongue - press your tongue against the roof of your mouth, then relax.
• Chest - breathe in deeply to inflate your lungs, then breath out and relax.
• Stomach - push your tummy out to tighten the muscle, then relax. · Upper back - pull your shoulders forward with your arms at your side, then relax.
• Lower back - while sitting, lean your head and upper back forward, rolling your back into a smooth arc thus tensing the lower back, then relax.
• Buttocks - tighten your buttocks, then relax.
• Thighs - while sitting, push your feet firmly into the floor, then relax.
• Calves - lift your toes off the ground towards your shins, then relax.
• Feet - gently curl your toes down so that they are pressing into the floor, then relax.

6. As you progress through the muscles, it is useful to periodically remind the patient to clear away any thoughts or worries from their mind, and to keep all the other muscles in the body relaxed as they progress through the exercise.

7. At the end, allow the patient to remain still for a few minutes and experience the feeling of relaxation throughout the body. Ask the person to slowly openly their eyes.

Tips:

• if the patient prefers, you can record the exercise on to a cassette to facilitate practice.
• when at home, the patient should find a quiet place to practice this technique.
• remind the patient that to benefit from PMR he or she will need to practice this form of relaxation at least once a day.
• making a regular time to relax, such as on awakening, will increase the likelihood of the patient using this technique.
• 15-20 minutes of PMR per day is ideal, but 5 minutes is better than nothing!

Slow breathing:
1. Provide the rationale for this technique:
When you get anxious your rate of breathing increases. This overbreathing is often referred to as 'hyperventilation'. When you overbreathe you breathe out too much carbon dioxide which leads to a decrease in the level of carbon dioxide in the blood. The decreased level of carbon dioxide causes or worsens a number of symptoms such as breathlessness or light-headedness. You may experience these symptoms if you have panic attacks. To get rid of these symptoms, the level of carbon dioxide in the blood must be steadied. One way of achieving increased levels of carbon dioxide is to breathe into a paper bag. A large proportion of the air you breathe out is carbon dioxide, therefore, by re-breathing your old air you are taking higher amounts of carbon dioxide into your lungs.

Although breathing into a paper bag is simple and effective, it may not always be convenient or socially appropriate to pull out your paper bag in public! Additionally, although breathing into a paper bag is effective during a panic attack, this method cannot prevent hyperventilation in the future. An alternative method which is less obvious to other people and more effective in the long run is the slow breathing exercise. This method will help you to control your hyperventilation. Also, by learning slow and regular breathing habits you will help to prevent future episodes of hyperventilation and other symptoms of panic.

The following exercise is to be practised four times every day for at least five minutes each time, AND at the first signs of panic or anxiety. Combining slow breathing with relaxation is particularly helpful.

(To be practised regularly and at the first signs of anxiety or panic).

1. Hold your breath and count to 6 (do not take a deep breath).
2. When you get to 6, breathe out and say the word relax to yourself in a calm, soothing manner.
3. Breathe in and out slowly through your nose in a six-second cycle. Breathe in for three seconds and out for three seconds. This will produce a breathing rate of 10 breaths per minute. Say the word relax to yourself every time you breathe out.
4. At the end of each minute (after 10 breaths) hold your breath again for 6 seconds and then continue breathing using the six-second cycle.
5. Continue breathing in this way until all the symptoms of overbreathing have gone. It is important for you to practise this exercise so that it becomes easy to use any time you feel anxious. It is helpful to time it using the second hand of your watch or nearby clock.

References and recommended reading:
1. Andrews, G., Crino, R., Hunt, C., Lampe, L. & Page, A. (1994). The Treatment of Anxiety Disorders. Melbourne: Cambridge University Press.
2. Bourne, E. J. (1995). The Anxiety and Phobia Workbook (Second Edition). USA: New Harbinger Publications Inc.
3. Barlow, D. H., Lawton Esler, J., Vitali, A. E. (1998). Psychosocial Treatments for Panic Disorders, Phobias, and Generalized Anxiety Disorder. In P. E. Nathan and J. M. Gorman (Eds.). A Guide to Treatments that Work. New York: Oxford University Press.
4. Davis, M., Eshelman, E. R., & McKay, M. (1995). The Relaxation & Stress Reduction Workbook (Fourth Edition). USA: New Harbinger Publications Inc.
5. Treatment Protocol Project (2000). Management of Mental Disorders (Third Edition). Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse.

What is it?

Skills training involves carefully constructed combinations of various cognitive and behavioural strategies in a manner designed specifically to treat the particular disorder and/or the specific difficulties the person is experiencing. Training involves the development of skills needed to deal with the situation that is problematic.

Does it work?
Various types of skills training are recommended for a range of disorders. The specific evidence for the various skills training approaches is discussed below.

How do you do it?
The different types of skills training (e.g., problem-solving) and how to do them is discussed below.

Problem-solving skills training

What is it?
Problem-solving skills training involves teaching the patient to follow a series of systematic steps to enhance their sense of control over difficulties that are encountered. Problem-solving is easy to teach and easy to learn, and can be applied to a variety of different problems such as: 'threatened-loss (e.g., of an important relationship or of personal status), actual loss, conflicts in which a person is faced with a major choice (e.g., whether or not to leave a situation, take on a new role), marital and other relationship problems, work difficulties (e.g., how to alter current working relationships), study problems, coping with boredom, difficulties concerning child care, and dealing with handicaps resulting from either physical or psychiatric illness' (Hawton & Kirk, 1989 p. 407).

Does it work?
Studies indicate that problem-solving is a useful component of treatment for patients experiencing a wide range of difficulties such as depression (Craighead et al., 1998), anxiety (Andrews et al., 1994), and adjustment disorders (Sahler et al., 2002).

How do you do it?
Before you begin, ensure that that patient's problem(s) can be clearly specified (this can take some time) and that the patient's goals seem realistic. Once this has been established, there are six main steps that you can begin to teach the patient:

Summary of steps in structured problem solving

1. Define the problem
2. List all the possible solutions
3. Evaluate advantages and disadvantages of each possibility
4. Choose the best strategy or combination of strategies
5. Plan how to implement chosen strategies
6. The chosen course of action is then implemented and the outcome reviewed.

1. Define the problem. It is important to clearly define the patient's specific problem(s). For problems that are not clearly defined (e.g., a patient reports 'financial difficulties') it is important to direct the patient to be more specific (e.g., 'how are your financial difficulties causing you problems?'). At other times, problems will occur episodically (e.g., 'difficulties with work colleagues'). In these instances, ask the patient to describe a recent situation when the problem occurred. Make sure you cover all of the patients concerns and write all of their specific problems down. Of these problems, decide with the patient which problem needs immediate attention or which problem is the easiest to solve. It is important that you only consider ONE problem at a time.

2. Generate and list all possible solutions. Then generate a list of possible solutions with the patient. This phase is often referred to as 'brainstorming', and you ask the patient to suggest as many solutions as possible, even they seem absurd or ridiculous. Encourage the patient to be creative and to remain non-judgmental at this stage. If the patient has difficulties generating possible solutions, make some suggestions to get the person started.

3. Evaluation. Briefly discuss the advantages and disadvantages of each possible solution.

4. Choose a solution. Then evaluate the potential solutions in terms of their consequences, how feasible they are for the person to implement and how well it meets the person's goals. Sometimes the patient should be encouraged to choose the solution that is most practical or that can be most easily applied, even if it is not ideal. It may also be useful to combine some of the solutions.

5. Planning. Once the action most likely to solve the problem, and which is practical for the person to carry out, is selected, it is useful to plan in detail how the solution will be carried out. This increases the likelihood that the plan will be carried out and that the problem will be resolved. (taken from MMD) The following checklist (adapted from a checklist developed by Ian Falloon) applies to any problem and will be helpful in pinpointing any pitfalls or obstacles in the solution plan. q Does the individual have the necessary resources (e.g., time, skills, equipment, money) or are you able to arrange the necessary resources, or personal or expert help?

• Does the individual have the agreement or co-operation of other people who might be involved in the plan?
• Does everyone in the problem solving exercise know exactly what they need to do and when they need to do it? Setting specified times or deadlines will minimise the risk of procrastination.
• Have all the steps been examined for possible difficulties?
• Has the individual planned any strategies for coping with likely difficulties?
• Has the individual planned any strategies for coping with any consequences that may arise? For example, if the individual applies for a job, what happens if he or she does not succeed? Or if they get a new job and have not considered what the demands of the job might entail?
• Have difficult parts of the plan been rehearsed? (e.g., a telephone call, conversation or interview)
• How will the steps of the plan be monitored? If the plan involves a number of people it will be useful to nominate a co-ordinator to monitor progress and to prompt and remind people when they need to do the things they agreed upon. Include this monitoring as part of the plan so that everyone agrees and is prepared to be reminded.
• Has a time and place been set for a review of the overall progress of the plan?

6. Review. The chosen course of action is then implemented and evaluated. Some modifications to the plan might need to be made and unexpected difficulties should be discussed. If it was not successful at all, another course of action might need to be selected, implemented, and the outcome again evaluated. The patient should be praised for any effort he or she has made, and where possible, successful outcomes should be rewarded.

Below is a structured problem-solving handout designed for use in the longer consultation as part of the Better Outcomes in Mental Health Care initiative.

Structured problem solving (Click here to go to a printable page)

Step 1: What is the problem?
Think about and discuss the problem or goal carefully then write down exactly what you believe to be the main problem or goal. The more time spent defining a problem that is specific, and potentially solvable, the better.

Step 2: List all possible solutions
Brainstorm and put down all ideas (generate 10 as a minimum), even bad ones. List all possible solutions without any evaluation of them at this stage.

Step 3: Discuss each possible solution
Quickly go down the list of possible solutions and assess the main advantages and disadvantages of each one.

Step 4: Choose the best or most practical solution
Choose the solution or combination of them that can be carried out most easily with your present resources (time, money, skills, etc.)

Step 5: Plan how to carry out the best solution
List, in small steps, how you intend to implement the solution. Identify the resources needed and the main problems that need to be overcome. Practise difficult steps. Take all the information needed with you (addresses, names, phone numbers).

Step 6: Record progress on the day by ticking above. Review how well the solution was carried out. Feel good about all efforts. Revise your plans if necessary. Continue the problem solving process until you have resolved your stress or achieved your goal.

References and recommended reading:
1. Andrews, G., Crino, R., Hunt, C., Lampe, L. & Page, A. (1994). The Treatment of Anxiety Disorders. Melbourne: Cambridge University Press.
2. Catalan, J., Gath, D. H., Anastasiades, P., et al., (1991). Evaluation of a brief psychological treatment for emotional disorders in primary care. Psychological Medicine, 21, 1013-1018.
3. Craighead, W. E., Miklowitz, D. J., Vajk, D. J., & Frank, E. (1998). Psychosocial Treatments for Bipolar Disorder. In P. E. Nathan & J. M. Gorman (Eds). A Guide to Treatments that Work. New York: Oxford University Press. 4. D'Zurilla T.J. & Goldfried M. R. (1971). Problem solving and behaviour modification. Journal of Abnormal Psychology, 8, 107-126. 5. Falloon, I. (Ed.). (1988). Handbook of behavioral family therapy. New York: Guildford Press.
6. Mynors-Wallis, L., Davies, I., Gray, A., et al. (1997). A randomised controlled trial and cost analysis of problem-solving treatment for emotional disorders given by community nurses in primary care. British Journal of Psychiatry, 170, 113-119.
7. Mynors-Wallis, L. M., Gath, D. H., Lloyd-Thomas, A. R., Tommlinson, D. (1995). Randomised controlled trial comparing problem-solving treatment with amitriptyline and placebo for major depression in primary care. The British Medical Journal, 310, 441-445.
8. Nezu, A. M. (1986). Efficacy of a social problem-solving therapy approach for unipolar depression. Journal of Consulting & Clinical Psychology, 54, 196-202.
9. Sahler, O. J.; Varni, J. W.; Fairclough, D. L.; Butler, R. W.; Noll, R. B.; Dolgin, M J; Phipps, Sean; Copeland, Donna R; Katz, Ernest R; Mulhern, Raymond K. (2002) Problem-solving skills training for mothers of children with newly diagnosed cancer: A randomized trial. Journal of Developmental & Behavioral Pediatrics, 23(2), 77-86.
10. Schulberg, H. C., Block, M.R., Madonia, M. J.. Scott, C.P., Rodriguez, E., Imber, S.D., Perel, J., Lave, J., Houck, P.R., Coulehan, J. L. (1996). Treating major depression in primary care practice. Eight-month clinical outcomes. Archives of General Psychiatry, 53, 913-919.

Anger management

What is it?
As the name suggests, anger management techniques aim to help the patient to better 'manage' or regulate their anger, rather than eliminate their anger entirely. In general, the goals of treatment are to teach the patient both cognitive and behavioural skills to prevent an anger response occurring when it is not appropriate. Typically, cognitive behavioural techniques such as relaxation, cognitive restructuring, problem-solving, and stress inoculation, are used in the treatment of anger problems. One common approach to treating anger was developed by Novaco (1975). Novaco extended Meichenbaum's stress inoculation training (SIT), which was originally developed for treating anxiety, and adapted it for use with anger problems (Meichenbaum, 1975). Essentially, patients are taught coping skills and then given an opportunity to practice these skills in containable situations (e.g., using role-play). The relationship between thoughts, emotions and behaviour is also explained to the patient, with an emphasis on teaching him or her how to regulate their thoughts and emotions to prevent an inappropriate anger response.

Does it work?
In the last 20-years, the most common approach used in anger management has been cognitive-behavioral therapy (CBT). A recent meta-analysis (Beck & Fernandez, 1998) indicated that on average, people with anger problems who are treated using cognitive behavioral techniques, do better than control subjects. Importantly, this effect was significantly different from what would be expected to occur by chance. CBT is therefore considered the optimal treatment for anger problems and continues to be used widely.

How do you do it?
The approach outlined here is based on Navoco (1979) and can be supplemented with other techniques, such as problem-solving, as appropriate. Stress inoculation interventions are divided into three phases: cognitive preparation, skill acquisition, and application training and each of these will be discussed in turn (although a thorough reading of Navoco 1975 is recommended). As with all treatments, different parts of the programme will be more relevant for some patients than others, and you will need to adapt the programme to the needs of individual patients.

Cognitive preparation. This stage may take a few sessions.
1. Firstly, you need to educate the patient about anger and explain the difference between adaptive and maladaptive anger. Provide examples.

2. Then you will identify the individual's anger patterns. This is best done by asking the patient to monitor their anger during the week and ask them to record details about the situation, what happened, how they reacted, and any other information you may consider relevant. Have them tune into the physical sensations that occur when angry (muscle tension, feelings of heat etc).

3. Next, introduce anger-management techniques that can be used by the patient when faced with conflict and stress. These include relaxation, cognitive therapy and problem-solving.

Skills acquisition. Again, you may need to spend a few sessions teaching and practicing the following techniques.

4. The next task is to teach the patient cognitive and behavioral skills, which will assist them to reduce their arousal levels. Standard cognitive therapy techniques, such as how to modify interpretations and expectations of anger inducing events, should be taught (refer to cognitive therapy section). It is common for patients with anger problems to have high expectations of themselves and others. It will therefore be important to challenge any irrational thoughts or beliefs and help the patient develop alternate ways of interpreting events.

5. Teaching the patient how to use self-instruction is also recommended. However, this is not simply a matter of teaching the patient to use statements such as 'don't get upset'. You need to teach the patient how to apply statements to specific situations. This is more effective than using one simple statement, as this one statement may be incongruent or inappropriate for the situation at hand, and thus serve to anger the individual further. To facilitate anger management, the patient must learn how to apply the self-instruction technique broadly. Novaco (1979) outlines a series of stages in the regulation of anger that make this process more manageable. These are:

(i) preparing for the provocation;
(ii) impact and confrontation;
( iii) coping with physical arousal;
(iv) coping with cognitive arousal
(iv) subsequent reflection;
(v) conflict unresolved;
(vi) conflict resolved.

In the first stage, explain to the patient that he or she will need to prepare for the situation at hand and modify any expectations they may have. Although not all situations can be anticipated, patients with chronic anger problems will tend to get aroused in fairly similar or predictable circumstances (you can usually get an indication of this from the patient's monitoring). In the second stage of anger regulation, the patient needs to learn how move into the 'problem-solving response mode' (p. 270) and generate statements that make them feel in control of the situation.

(Add an example that illustrates the cognitive work/coping strategies in an adult and with children)

In the next stages, the patient needs to monitor their arousal levels and implement coping strategies as necessary. Should the conflict remain unresolved, the patient should also be prepared to use self-instructions to stop themselves dwelling on the situation and use self-instruction to manage arousal levels in the face of unresolved anger.

The following table from Novaco (1979, p. 269) provides useful examples of self-instructions that the patient can use to regulate anger.

Self instructions for the regulation of anger

Preparing for a provocation
This could be a rough situation, but I know how to deal with it.
I can work out a plan to handle this.
Easy does it.
Remember, stick to the issues and don't take it personally.
There won't be any need for an argument. I know what to do.

Impact and confrontation
As long as I keep my cool, I'm in control of the situation.
You don't need to prove yourself. Don't make more out of this than you have to.
There is no point in getting mad. Think of what you have to do.
Look for positives and don't jump to conclusions

.Coping with arousal
My muscles are getting tight. Relax and slow things down.
Time to take a deep breath. Let's take the issue point by point.
My anger is a signal of what I need to do. Time for problem solving.
He probably wants me to get angry, but I'm going to deal with it constructively.

Subsequent reflection

• Conflict unresolved
  • Forget about the aggravation. Thinking about it only makes you upset.
  • Try to shake it off. Don't let it interfere with your job.
  • Remember relaxation. It's a lot better than anger.
  • Don't take it personally. It's probably not so serious.

• Conflict resolved
  • I handled that one pretty well. That's doing a good job.
  • I could have gotten more upset than it was worth.
  • My pride can get me into trouble, but I'm doing better at this all the time.
  • I actually got through that without getting angry.

  ---

6. The next important step is to teach the patient anger-management skills. The goal is to teach the patient how to use skills that are incompatible with anger, such as relaxation. Progressive-muscle <relaxation> (PMR) is recommended. PMR teaches patients how to become aware of the areas where they are tense and provides a sense of control over their arousal levels.

7. Verbal communication and problem-solving skills also need to be taught to the patient, as it has been found people with anger problems tend to lack such skills. An outline of these techniques is provided elsewhere (link to communication and problem-solving) and can be incorporated into anger management training.

Application training.
This is the final stage and again, will need to be spread over a number of sessions.

8. Patient's now need to be given opportunities to apply their newly acquired repertoire of cognitive and behavioural anger-management skills. Initially, this can be done by asking the patient to imagine anger inducing scenes and have them apply their techniques imaginally. This should then progress to role-playing a variety of anger provoking situations with the patient. Then, once sufficient mastery has been achieved, the patient should move to in vivo practice. Imaginal, role-play and in vivo practice situations can be arranged in a hierarchy, from least to most anger provoking, to ensure that patient's practice these skills in a gradual manner to ensure that they do not become overwhelmed.

References and recommended reading:
1. Beck, R. & Fernandez, E. (1998). Cognitive-behavioral therapy in the treatment of anger: a meta-analysis. Cognitive Therapy and Research, 22(1), 63-4.
2. Novaco, R. W. (1979). The cognitive regulation of anger and stress. In P. C. Kendall & S. D. Hollon (Eds.). Cognitive-Behavioral Interventions. Theory, Research, and Procedures. New York: Academic Press.

Communication training

What is it?
The aim of communication skills training is to teach individuals and families how to discuss their thoughts constructively and successfully. Sometimes it may be necessary to make a simple request, such as asking for a favour or for someone to change his or her behaviour in some way. At other times people may want to talk about very important and complicated issues without causing major arguments and hostility.

An important point to remember about interpersonal communication is that some people will react in an angry and hurt manner even when an individual has communicated politely. Inappropriate behaviour in response to polite and reasonable requests or statements is a sign that the other person may have difficulties with some aspects of their own interpersonal communication. It is important to be able to recognise inappropriate behaviour in others so that individuals do not continue to blame themselves for other people's shortcomings.

Does it work?
Communication training, and variants of this training, have been used to treat a wide variety of problems and disorders. The application of communication skills has been broad and includes students with learning disabilities (e.g., Brunello-Prudencio, 2001), parent-adolescent conflict (e.g., Barkley et al., 2001), carers (Done & Thomas, 2001), alcohol and drug dependence (Monti & O'Leary, 1999) and medical students (Winefield & Chur-Hansen, 2000). Despite this variety of applications, the results tend to be favorable. However, the exact components of this training that lead to the desired changes in behaviour are unclear. Thus, training should be tailored to suit the individual based on the evidence for their particular communication skill deficit.

How do you do it?
The following guidelines, taken from the Management of Mental Disorders (2000), provide simple strategies that will help you teach your patient to improve their communication skills. The basic rule is to keep messages simple, clear, and positive.

1. Making clear, simple statements or questions. Clear and simple statements are always important. The rules for making clear, simple statements or questions are outlined below.

• Use short statements or questions
• Ask one question or make one request at a time
• Be specific (e.g. Instead of saying, "I'd like you to try getting up earlier" say, "I'd like you to try and get up by 10 o'clock".)
• Avoid strong emotional statements (e.g. "I can't stand this disgusting mess!")

2. Praising someone. Everyone needs to be appreciated and told that they are OK. Sometimes, however, people forget to express their positive feelings about other people. Explain that if you praise people for their good behaviours, nice appearance, etc., they are more likely to continue with those behaviours. Just as important, praise can help others to feel good about themselves. Rules for praising someone:

• Look at the person
• Say exactly what he or she did that pleased you
• Tell the person how you feel
• Give praise for even small accomplishments - do not wait for major change
• Praise people immediately after they do something pleasing
• Avoid 'back-hand' compliments (e.g. "That was a really nice thing to do, but...")

3. Asking someone to do something. Explain that if you want someone to behave in a particular way or do something for you, you are not likely to be successful if you sound like you are 'nagging', or demanding, or making the other person feel guilty in some way. Generally, if you want to ask someone to do something in particular, you should state clearly exactly what you would like that person to do. You should also tell the person how much you appreciate his or her effort. A request that is phrased in a nice way is more likely to be successful and is less likely to cause resentment. Rules for asking someone to do something:

• Look at the person (make eye contact)
• Say exactly what you would like that person to do (be specific)
• Say how you feel

You may like to use phrases such as:

• "I would really appreciate it if you would...."
• "It would make a big difference to me if you would help me with the ...."
• "If you could ... I would really feel a lot more relaxed."

Remember that your tone of voice and your body language also give very strong messages. There is no point in asking someone to do something if you are standing with your hands on your hips and speaking in an angry or sarcastic manner.

Remember also that sometimes even clear and pleasant requests will be ignored. Perhaps the request was unreasonable. Or maybe the other person was feeling too troubled or too inconsiderate to help.

4. Expressing negative feelings. Negative feelings include such things as anger, frustration, disappointment, sadness, envy, and fear. If negative feelings are not expressed, other people will never know that