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CBT interventions for patients with advanced disease: psychological
approaches in a palliative care setting
Kathryn Mannix
Newcastle upon Tyne Hospitals NHS FT and Marie Curie Hospice, Newcastle.
CBT theory
• There is a link between thoughts, emotions and behaviours, and these can influence and be influenced by attention and physical symptoms.
• Our automatic thinking is not necessarily accurate or balanced.
• Our behavioural responses do not necessarily help us to feel better.
• We can learn to notice and modify unhelpful thinking and behaviour patterns.
The hot cross bun model
thoughts
moods
behaviours
bodily
sensations
I’m going to die.
It’s my fault.
I’ll choke
moods
behaviours
bodily
sensations
New lung cancer diagnosis
thoughts
breathlessness
secretions
dry mouth
cough
swallowing monitor for problems
avoid triggers – do less
check swallows
ruminate & worry
anxiety
panic
guilt
sadness
CBT style
• Collaborative empiricism
• Curious questioning, Socratic dialogue
• Formulation-based
• Builds understanding, skills and knowledge in the patient
• Problem-focussed
• ‘short term’ therapy
• …so how short is ‘short term?’…
0
2
4
6
8
10
12
14
<1 m 1-3m 3-6m 6-12m >12m
life expectancy at referral
life expectancy of 39 palliative care
patients at referral for CBT
outcome n sessions
died before assessment 1
not suitable 2 1
didn’t engage 2 1
problem-solving approach 7 3 (2 - 6)
behavioural only 4 3-4 (2 - 5)
limited CBT 8 5 (2 - 7)
schema-level work 12 6 (2 -16)
panic work 1 1
in therapy 5
total 42
Outcomes 1
alive & well …………………………………..4
dead - no psych relapse …………………...11
advancing disease, no psych relapse ……………...5
effective single intervention …………………….3
in therapy & making progress …………………….4
initial response, but relapsed with adv. disease …...3
lost to follow up …………………………………...2
data missing …………………………………...1
total successful interventions 30/39 …………… 76%
Thinking traps
• Traditionally, CBT has labelled hot thoughts as ‘biased’ or ‘negative.’
• In a palliative care setting, reality is often bad or worse…
• Re-labelling thoughts as ‘helpful’ and ‘unhelpful’ is a more realistic and adaptive model.
The advanced disease reality:
• Things are bad – but some things are still good.
• Energy is lower, and may be unpredictable.
• Physical symptoms may be the focus of the CBT work, or may need to be worked around to address emotional needs.
• Patients may be unwell or disabled, making activities difficult and challenging their roles or responsibilities.
• Sessions may need to be brief, and may still be terminated abruptly.
Thinking traps and self-defeating behaviours
I can’t do it like I used to
It’s not worth trying
I’m useless
(I’m a useless mother/husband/parent/boss/artist…)
Don’t try
Planned Activity and predicted outcome
Tuesday: Wednesday Thursday:
Pleasure
Predicted/ actual
Satisfaction predicted/ actual
Difficulty predicted/ actual
What I found out: …………………………………….
Planned Activity
Tuesday:
Get washed before wife arrives
Wednesday: Use the bath with the help of the nurses
Thursday am:
Put my clothes on
Thursday pm: go on trip to Garden Centre
Pleasure
P/A
6
6
7
9
4
7
7
8
Satisfaction P/A
6
9
4
6
4
7
6
4
Pain
P/A
8
5
8
6
7
5
6-7
6
Things don’t seem to hurt as much as I expect. Even though I was a bit sore, I felt pleased to be doing things again. I feel more confident. I can take extra doses of painkiller if I need to, and that really helped at the Garden Centre. I could do more for myself and I could probably
manage at home with some help.
Styles of CBT in palliative care
• formal CBT – contract with trained therapist
– 6 - 12+ regular sessions
– homework
– formulation elaborated and shared with patient
• use of CBT techniques: ‘First Aid’ – guided discovery
– simple formulation
– recognition of thinking and behavioural traps
– explanation of panic
– discovering and defusing catastrophic thinking
– intervention techniques
– access to supervision
Key Skills for CBT First Aiders: • Socratic questioning; guided discovery
• Collaboration, enquiry and curiosity
• Formulation
• Goal setting
• Empowering change
• Experimenting, challenging, finding out
• Recording; measuring change
And avoiding:
Reassurance; giving advice; stopping when distressed
What do trainees say?
0102030405060708090
CBT skills training has: %
Improved my clinical practice 92
Made little difference to my practice 3
Had adverse effect on my practice 5
Enabled me to notice problems I did not notice before
56
Enabled me to tackle problems I did not address before
74
Enabled me to refer on problems I did not address before
33
Skills Pyramid: CBT skills for psychological support in NECN
scarce
8
?
many
Tier 4: experts in liaison psychiatry and clinical
psychology (includes CB Therapists)
Tier 2: NECN Level 2 training
Tier 1: Advanced Comms Skills training run by NECN
Foundations in CBT run by RVI and others
Tier 3: Diploma in CBT
2 cons; 3 CNS/nurse cons;
1SW pall care
2 CNS/nurse cons Ca/LTC
98
Post-training success stories - 1 • I have recently completed a course of CBT FA with
a patient who suffered from frequent panic attacks when in enclosed spaces from which he cannot easily escape.
• He has recently been able to manage a 4 hour coach journey (about which he was extremely anxious) and he did not have a panic attack!
• I helped a patient with panic attacks; he learned techniques to manage his panic which he used to get him through his terminal haemorrhage.
Post-training success stories - 2 • Vignette from course participant
(After 2 training days and 1 supervision
Hospice ward nurse caring for elderly, isolated single man who rejects care as ‘fussing.’
• Using , nurse establishes that patient’s pride is offended by receiving care, yet also by appearing unkempt.
• Using and , patient is enabled to to wash and shave himself, sitting in the bathroom
(not in bed!) and invite help if he becomes tired
• Nurses provide bowl, soap, razor and privacy;
• Patient succeeds, is delighted and exhausted. Allows nurses to help him back to bed.
• This patient died peacefully 5 hours later.
Key messages
• CBT is an effective intervention in a seriously ill population of patients.
• ‘Unhelpful’ thinking and behaviour is a more useful concept than ‘negative thoughts.’
• Non-mental health professionals can be taught to deliver effective CBT-derived interventions.
• NECN is leading the UK in developing its workforce in this way.
Skills practice using patient scenario
• Work in pairs
• Choice:
– Discuss exercises on the sheet
– Use scenario to practice talking to a ‘patient’ about negative thoughts with realistic content
• Be a helpful patient
• Use only questions and summaries
• Keep checking you have understood by paraphrasing the patient – you will have to say some of their difficult thoughts out loud: how does that feel?
