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«Innovations in CBT for Treatment Resistant OCD and BDD James M. Claiborn Ph.D. ABPP ACT Riverview Psychiatric Center Augusta Maine Characteristics of ...»

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• If we begin by simply listening to the patient and trying to understand their experience we can begin to build a helping relationship. This alone may have considerable impact on their mental status.

• We can work toward an open dialogue about the experience of the voice and how to deal with it.

What is the Real Problem with “Psychotic” Symptoms The actual beliefs and explanations of experience ● are not a problem in and of themselves.

The problem is the distress associated with the ● experience or belief or the interference with function that follows from the beliefs.

With this in mind the goal of therapy is not ● necessarily to change the belief but rather to change the effects of the belief, reduce distress and interference.

What are safety behaviors and why are they a problem?

• Safety behaviors are things someone does to get relief where they believe that if they did not do them some disastrous consequence would follow. A classic example is the panic patient who takes a Xanax and believes it saves his life. The problem is that such behaviors actually reinforce the belief in the danger of the symptom and the magical belief that the coping response was all important in preventing a disaster.

This perpetuates the disorder and distress associated with the symptom Joining in the patients conceptualization In order to work with patients who have ● delusional beliefs we need to first join with them in conceptualization.

This includes accepting that they are reporting ● their experience as they understand it and their beliefs represent their efforts to make sense of those experiences.

Working with Delusions Begin with an individual formulation that ● accounts for the patients beliefs and associated distress.

What evidence is the person using as the basis for their beliefs?

How do these ideas build on the persons ideas about self, others and the world?

How do these thoughts make sense of previous life experiences?

Problematic Beliefs Supported by Mental Health Professionals There are some beliefs about symptoms which ● may contribute to treatment resistance and which are supported by popular conceptualizations or other mental health professionals who have interacted with the patient.

Depression is anger turned inward and expressed only by a compulsion. If not expressed the anger would lead to aggressive behavior Continuing Work with Delusions Is the individual reacting to puzzling, confusing or otherwise ambiguous experiences?

How is the person reasoning about experiences?

Recognize known biases ● Bias for confirmatory information Tendency to jump to conclusions All or nothing thinking Feed back this formulation to the patient In effect the reasoning of the client is “unpacked” and treated as understandable in a normalizing and empathetic manner.

Therapy Process Develop alternative interpretations of anomalous ● or other distressing experiences.

Review evidence supporting interpretation and ● alternative explanations of experience Develop the ability to become an observer and ● evaluate thoughts rather than simply accepting them.

Working from the Outside In The effect of confrontation of delusions is ● typically to lead to greater entrenchment.

Therapeutic efforts may be more acceptable if ● you begin with less central beliefs.

Using the approach of working with more ● peripheral beliefs first and working with toward more central ones is less likely to be met with resistance and may lead to acceptance of the process of developing alternatives.

Peripheral Questions In discussing any delusional or overvalued idea ● it is best to explore the belief beginning with more peripheral elements and by examining details and possible inconsistencies. With the use of Socratic questioning and with the understanding that beliefs are rarely held with absolute conviction an approach that is both accepting and mildly skeptical is likely to lead to reevaluation of the belief.

No Safety Behavior Please!

• There are a number of techniques that have been found helpful in dealing with hallucinations but they must be used in context.

• Both Therapist and patients need to understand that the use of these methods is a way to be more comfortable as the voices can be unpleasant or annoying but that it is not “necessary” to get rid of the voices.

Behavioral Experiments Often confused with exposure exercises.

● Determine a specific thought or belief to be ● tested.

Determine what information is needed to ● conduct this test.

Set up an experiment to gather this data.

● Establish in advance what a particular outcome ●

–  –  –


How much do you believe the thought now?

● To what extent were predictions confirmed or ● disconfirmed?

What is a realistic view given the results of the ●

–  –  –

other cognitive approaches to belief change the attitude of the therapist plays a critical role.

Because the beliefs we describe as over valued ● or delusional are typically held with strong affect any indication of a non accepting attitude by the therapist is likely to be damaging to the already fragile working alliance.

Work on Values If overvalued ideas are more of a problem ● because of firmly held values than because of their content then work focused on those values has the potential to lead to important change.

Example A person who values perfection may be treatment resistant since the goal of treatment seems to be to accept imperfection. The effect and desirability of seeking perfection can be examined and the reconsidered.

The Role of Mindfulness Mindfulness as a special kind of attention ● without judgment or evaluation Since it is not the intrusive thought but the ● evaluation or judgment that is the source of distress a mindful response to the intrusions leads to reduction of distress Mindfulness can be viewed as a skill which can ● be developed with practice. This may begin with practice of mindful attention to non distressing stimuli Wells and Attention Training Based in Wells SREF model ● Successfully used in case studies with panic and ● hallucinations Attention Training Technique ● Application to excess attention to detail in OCD ●

–  –  –

Based in the work of J. Young ● Early maladaptive schema serve as prototypes ● for automatic thoughts Delusions may emerge as a result of invalidation ● of personal schema and may serve to protect against loss of self-esteem or other threat Schema are responded to in one of 3 ● fundamental ways. Overcompensation, Confirmation/ Surrender, or Avoidance Steps in Schema Work Rationale: Use of prejudice model ● Identification of schema using Socratic ● questioning and downward arrow Use of historical testing ● Use of responsibility pie ● Use of continua to evaluate schema ● Review of advantages/disadvantages of a ● schema or belief Development and testing of alternative schema ● Motivational Interviewing First developed for work with substance abuse ● clients where treatment resistance is often extreme Therapists are taught to roll with the resistance ● and enhance ambivalence Adopted for treatment of hoarding (a particularly ●

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