Dr. Ed Neuhaus' blog on Flexible CBT: why and how it's valuable for your clinical practice, and tips on getting the most out of the web-based training program.
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The games are designed to play multiple times, and each time you play you will answer questions faster and get higher scores. Faster response time means you are processing the information more effectively, and your mastery is increasing.
Some of the games can be frustrating initially. The Hangman game is a case in point. A seemingly simple game format, yet a powerful learning tool. Many people (including myself) have commented that when they first play this game they don’t know what’s going on. My advice: start typing. It is a fill in the blank game requiring exact answers. If you don’t know the answer, keep typing and eventually you’ll get there. When you play the game again you’ll be surprised how quickly you improve and remember the material.
The key point: practice by playing the games multiple times, your speed will increase, and in the process you will improve your comprehension and mastery.
Posted by Ed on Dec 22, 2010
Learning games are a key feature of the online training. I recommend you do the games while you’re reading the QBook. The idea is not to study for the “test” before you do the games; rather, the games are a primary way to study and practice. You can play them as many times as you need to in order to reach the criterion level score (70% to earn CEUs). In the process, you will meet the real objectives: enhance your comprehensive and mastery of the content so that you can improve your effectiveness with patients.
Open Game Windows while reading text in QBook. This takes a bit of finesse. As you get more skilled with the online system, you will easily manipulate the windows for sizing and placement: you can open a game for a specific QBook section and go back and forth between the game and the text.
Posted by Ed on Dec 19, 2010
Treatment is a learning process, for patients as well as for therapists. I put the Flexible CBT Approach in an online format for two reasons: 1) the technology requires your active involvement in the learning which leads to better comprehension, memory, and mastery of the material; and, 2) online delivery is scalable such that many clinicians have access to this training anytime, anywhere.
Let’s consider how the learning instruction technology enhances your learning. It starts with text like any book and it actually looks like a book on the screen. But it is not like any hard copy book. We refer to it as the QBook and it looks similar to an iPad e-book on your screen.
First is navigation: you can navigate easily from the table of contents, point an click to any chapter section and you’re there, and back again. You can bookmark pages, highlight sections, and make notes wherever you want. When reading the text you have many options to interact: you make choices to point and click-on pop-ups for graphics that illustrate concepts spatially or provide background material; click on a hot-link for a pdf that might be background information or a handout to give to your patients. Brief video instruction segments are embedded in the book. In various sections you read about something, see a graphic, and look at a video.
This is truly multi-modal learning as you must use different parts of your brain to process information, and in the end, learn more effectively.
Posted by Ed on Dec 19, 2010
The online program in Flexible CBT is organized into three specific modules.
Module 1: Fixed Values— the foundation of the approach. Fixed Values are the guiding posts of the Flexible CBT Approach that establish the foundation for clinical decision-making to optimize the matching of treatment interventions to a patient’s problems.
Module 2: Assessment and Establishing the Therapy Relationship: Learn the Cognitive Behavioral Analysis (CBA) to establish a sound treatment plan and case formulation, and equally important, how to start a productive therapeutic relationship.
Module 3: Skills Training and Psychoeducation: Learn principles and protocols to apply with your patients and help them improve functioning and enhance quality of life.
Tip: Fixed Values permeate all aspects of the Flexible CBT Approach. You can always connect an intervention or clinical decision back to one or more of the Fixed Values.
Tip for earning CEU: Concentrate on one module at a time and complete the games. Then move onto the next module.
Posted by Ed on Dec 14, 2010
For most people, information about psychotherapy, or any mental health treatment, is a mystery.
People often have preconceived notions that they will be required to delve into their past but not sure why, will have to take medication, and often figure that they don’t know best and need their therapist to tell them.
Psychoeducation refers to being educated about a psychiatric/psychological condition, whether one is a patient, a family member, or someone not in treatment but interested in learning about a particular topic. Ideally, psychoeducation is part of the standard of care that is provided by therapists or others in the mental health system.
I take it one step further: Collaborative Psychoeducation. It is the education plus incorporating it as a part of treatment so a patient and family can use the information to be more actively involved in decisions about treatment. The collaboration becomes an open dialogue.
My view: accurate information translates into a sense of control for people. If they are informed about the therapy they are in, what to expect, the condition they’re struggling with, medications, side-effects, whatever–they will be more actively involved in their own treatment, and this will likely improve their response to treatment.
Therapy is about change, and for lasting change people must find ways to make it meaningful and worth more than maintaining the status quo.
Most people view anxiety as an emotion or feeling, which is true but only part of the story. When I talk to people about anxiety I help them see that yes, they have anxious feelings, as well as anxious thoughts and behaviors. In many respects, it is focusing on changing the thoughts and behaviors that will have the biggest impact on diminishing the emotional suffering.
A classic example of anxious thoughts is worrying. Worries are thoughts that people go over and over in their heads. The more worry, the more anxious feelings. The “what ifs” of worrying are toxic because people start believing them, despite the fact that there is little or no evidence.
Anxious behaviors? Number one is avoidance: stay away from something or a dreaded task, or isolate from people. In the short-term anxious feelings may subside; unfortunately, avoidance doesn’t improve the situation, it only puts it off for another day and may even feel worse.
In the online Flexible CBT training program that I developed at McLean Hospital, an affiliate of Harvard Medical School, to help clinicians work more effectively with patients, there is a section focused specifically on Collaborative Psychoeducation for anxiety and specific skills to manage it.
People with anxiety often feel out of control. We get to the heart of the matter by helping people “control what they can control” to get them started moving in the right direction to manage their anxiety to improve their functioning and enhance their quality of life.
Posted by Max Woolf on Aug 10, 2011
A decade ago, Psychoeducation was not even considered to be a legitimate therapy intervention by many therapists. Mainstream therapy circles viewed psychoeducation as an add-on to therapy; it was only being utilized to its fullest potential to facilitate effective treatment in small, disparate pockets. The world is different now. Psychoeducation is an integral component of evidence-based CBT, whether the treatment is more cognitive, behavioral, a combination thereof, DBT, or ACT. Today, informed patients are more actively involved in their own treatment!
Taking the Mystery Out of Therapy
When I was clinical director of the Behavioral Health Partial Hospital Program at McLean Hospital/ Harvard Medical School, I learned about the power of psychoeducation. In the late 90s, it was more typical for patients NOT to know their diagnosis, and if they did, they usually lacked basic information about the course of illness and the available treatments. In the partial hospital program, we had psychoed groups for depression, anxiety disorders, bipolar disorder, and then in 2001, we introduced the first psychoed group for borderline personality disorder. Patients could simply not get enough of it. All of a sudden, patients were informed. They felt validated and less alone. The result? They were empowered to take action because they had a roadmap to learn skills and improve their functioning.
Psychoeducation and Clinical Practice
In my clinical practice, I start psychoeducation in the very first session after listening to my patient’s story and providing feedback. I start with the CBT triangle—thoughts, feelings, and behavior. In my practice, I do many consultations (and treatment) for patients suffering from treatment refractory depression. I recently saw a patient with poor outcomes from numerous therapies; he had never been exposed to CBT. I used my CBT triangle handout to illustrate the pattern of how his feelings were driving his thoughts and behaviors. When he feels down, he has thoughts of doom, and this causes him to hide out in his house—classic avoidance behaviors. It was like a light bulb went off in his head: “You mean I can learn how to do this differently?” Yes, you can. The simple power of psychoeducation helped him understand the process of how the treatment was working for him.
Posted by Max Woolf on Jun 29, 2011
PTSD often has co-occurring functional problems including mood disturbance, general anxiety, social isolation, negative thought patterns, and high vulnerability to stress. Clinicians can use Flexible CBT to complement specialized PTSD treatment, in effect, to fill in the gaps.
Self-Assessment is a key concept that can really help patients suffering from PTSD. Self-assessment is a cognitive skill of structured self awareness to identify patterns (see the online training MODULE 1, page 30, and MODULE 3, pages 30-35). When a person knows his patterns, he is more likely to identify triggers and be proactive. And the best way to be proactive is to know skills to use when encountering high risk situations or even after being triggered.
I like to put it in plain language for my patients: “self-assessment is a set of skills to help you do more of what works for you, and do less of what doesn’t work for you.”
Posted by Ed on Dec 27, 2010
I just heard a question: “my patient had an emotional reaction to something in her life and wanted to talk about it, but is that okay in CBT because it wasn’t part of the session agenda and protocol?”
The context of the question is this: The clinician was relatively new to CBT and her CBT training was oriented to adhering to a protocol for depression. She knows the protocol, is skillful at applying it, but then was presented with a situation that didn’t fit in the box. I’ve heard this question hundreds of times, and will hear it hundreds of times more. This is exactly why I developed Flexible CBT! We must use clinical judgment that will stray us from the protocol at times in order to help our patient ultimately stay on track. If this were a research protocol, my advice would be viewed as non-adherent to the protocol. This is not research. It is real life that doesn’t proceed in a linear fashion.
My answer to the question: if the patient has a strong emotional reaction to some life circumstance while you’re in session (not exactly in line with the immediate treatment goals), you have to use your clinical judgment to decide how to address this. To me, the issue is not whether your patient talks about it; it’s there in the room already. How you and she process it is the heart of the matter. Sometimes it’s a matter of acknowledging that this is important to your patient and give her time to talk about it. Then make a transition back to the session agenda: “do you feel ready to get back to the agenda we’ve been working on?” If yes, proceed. If no, then this could be an opportunity to actively use skills to manage the situation, or maybe to highlight how this situation is an example of her day to day struggle to manage her emotions, or maybe it reflects a core belief. Going forward, if something like this keeps coming up in sessions, then you must point this out to her and work together on figuring out how to stay on track to move ahead.
BOTTOM LINE: Flexibility works best when you stay oriented to the goals of treatment. Flexibility goes awry when treatment meanders to whatever new issue comes up in session and you lose sight of the goals you and your patient have agreed upon.
Posted by Ed on Dec 24, 2010
Here is an example of flexible clinical decision-making (from MODULE 3, Behavioral Coping Section).
Principles of Behavioral Activation: Life structure is a necessary component for healthy functioning. People often make emotionally driven decisions, and people suffering from depression, anxiety, PTSD, personality disorders are susceptible to waiting to feel better before doing things. The idea is to make plans to structure time in advance. This reduces the likelihood of emotionally driven decisions.
Protocols for Behavioral activation: Activities planning for the following areas: mastery activities (work, obligatory things like laundry, errands, etc.); pleasurable activities; self-care; and, interpersonal. The typical protocol involves a written sheet with a daily /weekly schedule, and filling it up with activities from all areas.
Flexible decision-making using principles: Patient feels overwhelmed just completing the activities plan. He knows it is important to structure his time, but is stuck. Or, we complete the plan in session and next session he reports he didn’t do anything. Now what? I go back to the principle: create structure and disentangle the negative emotion from the activity. Patient is depressed and anxious and a full activities plan is too challenging.
>>Clinical Decision: scale back activities plan to do one thing. Don’t worry about covering all four areas. Talk with your patient how to increase the likelihood of doing that one thing even if feeling anxious or stuck. In effect, I adjusted the protocol to meet the needs of my patient to get some momentum going towards positive change. Once we get some traction, then we can use the more extensive protocol for activities planning.
Posted by Ed on Dec 22, 2010
Principles are broad guidelines based on the concepts of theory and research. Protocols are specific interventions for specific problems.
Most of evidence-based CBT has been developed for a diagnosis: depression, panic, social anxiety, PTSD, substance abuse. Participants in research studies are typically homogeneous groups with one diagnosis. This “controls” for the diagnosis so that protocols can be tested and researchers can be confident that the protocol is effective for this type of patient. Very important, but there is an inherent limitation. In real world clinical practice, these diagnostically “pure” patients don’t show up very often. Instead, we see heterogeneous patients with depression, AND anxiety, AND a personality disorder. Or, maybe someone suffering from PTSD who also has depression, AND substance abuse, AND something else.
Flexible CBT is about fitting protocols to patients, rather than trying to fit patients to protocols. It starts with the seven Fixed Values that provide a framework. Principles help you determine priorities for treatment in the context of an individual patient’s needs, which in turn inform your decision-making to choose a protocol to address a specific problem. When you run into roadblocks, the principles help you stay focused on the priorities of treatment while you’re figuring out ways to tweak things to be more effective for your patient.
Principles and Protocols are introduced in MODULE 2.
Posted by Ed on Dec 22, 2010
Flexibility works as long as there are anchor points and ways of keeping track of where you are. Otherwise, we can be flexible, get disoriented, and drift far away from our objectives.
Fixed Values represent an aggregation and integration of key principles of CBT, the therapeutic alliance, learning theory, self-efficacy, and common sense. At any given time in treatment, all seven fixed values are relevant: The CBT Triangle of Thoughts, Behaviors, and Feelings; Functional Improvement; Skill Acquisition; Collaboration and Connection between therapist and patient; the role of Evidence-based interventions; the patient’s life context; and, treatment is a learning process.
Whether I’m working with a straightforward patient, or one with multiple diagnoses who presents many challenges of where to start and how to proceed, Fixed Values are my guide. I designed the Flexible CBT Approach so that Fixed Values inform your clinical decision-making and allow you to be flexible while staying on course to reach the goals of treatment.
Module 1 is organized according to the seven fixed values. In Modules 2 and 3, I connect the dots between the interventions/skills and the Fixed Values that inform them.
Posted by Ed on Dec 22, 2010
Early in my career at McLean Hospital, I saw the power of CBT for patients who otherwise were languishing with non-directive, interpretive therapy. It seemed obvious. CBT offers practical skills for patients struggling to function better and get life back on track—thought record/mood monitoring, cognitive restructuring, behavioral activation, and structured problem solving, but I was getting stuck when I tried to use the protocols that were validated in the research studies.
Back then around 1990, my typical patient did not fit into any neat category. It was usually some combination of diagnoses: a mood disorder, almost always some anxiety, often a personality disorder, and frequently a history of trauma with PTSD symptoms.
The typical path to develop CBT protocols is to test them with a diagnostically homogeneous patient population, such as depression, or panic, or social anxiety. Protocols are designed with a specific timing and sequence as inherent components for validation, and with the implicit assumption that patients would cooperate and adhere with the protocol, thus leading to desired outcomes.
The big challenge for me was the patients I was treating were very different than the patients in the research studies. They were diagnostically heterogeneous, wanting change but also resistant to it, and often at more severe levels of impairment than the patients in the research studies. And, I was trying to fit the protocols to these patients and getting frustrated. I needed to figure out a better way to work with the patients sitting across from me.
At the time I didn’t know it, but this was the start of my path to develop Flexible CBT.
Posted by Ed on Dec 14, 2010