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Transforming Mental Health: A Three-Step Protocol for Brief Cognitive Behavioral Therapy

This concise guide outlines a three-step protocol for Brief Cognitive Behavioral Therapy (CBT) developed by clinical psychologist Paul Rijnders. Focusing on shared problem definition, behavior change, and relapse prevention, this protocol aims to enhance patient commitment and self-directedness. It addresses the challenges faced by individuals with mental health issues, noting that only 25% to 55% receive treatment. The protocol emphasizes cognitive restructuring, behavior experiments, and decision-making, encouraging a proactive approach to mental well-being.

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Transforming Mental Health: A Three-Step Protocol for Brief Cognitive Behavioral Therapy

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  1. From Symptom to Solution:a brief, 3 step protocol for CBT Paul Rijnders Clinical Psychologist Indigo Zeeland, The Netherlands (www.kortdurendetherapie.nl) 2011

  2. Brief CBT: motives • Unbalance demand and supply • Changing expectations • Costs • Negative image • High threshold

  3. Brief CBT: requirements • Low threshold • Plain case concept • Easy to transfer / to learn • Enhancing commitment / Self-Directedness • Long lasting

  4. Questions • How many people suffer from serious mental problems? 7 - 8 % • Which percentage of this group receives professional mental health treatment? between 25% and 55% (differs per country)

  5. Question What works in CBT ?

  6. What works in CBT? • Cognitive restructuring • Behaviour experiments / activation • Shared Decision Making (targets and pathways) (helping patients to become aware of their strenghts and weaknesses and to convert weaknesses into power)

  7. 3 Steps • Shared Problem Definition (S.P.D) (emphasis on coping style / (discouraging) habits) • Behaviour Change (B.Ch) (learning to improve coping style by observing, comparing, reflecting, imitating and experimenting) • Relapse Prevention (R.Pr) (what triggers? How to anticipate?)

  8. 3 steps, 8 sub-steps • SPD : - Restoring overview - Finding connection - Formulating targets / treatmentplan • BCh : - Habits + alternatives - Behaviour change by imitation / social learning - The power of thoughts - Challenging of thoughts • RPr : - Termination and relapse prevention

  9. 3 steps, 8 sub-steps, 4 measurements M. 0 • SPD:- Restoring overview - Finding connection - Formulating targets / treatmentplan M. 1 • BCh:- Habits + alternatives - Behaviour change by imitation / social learning - The power of thoughts - Challenging of thoughts M. 2 • RPr:- Termination and Relapse Prevention M.3 (after 4 months)

  10. Measurement 0:

  11. Questionaires: (OQ-45) • Gegevens van patiënteGeboortedatum: 1978 Geslacht: VrouwBehandellocatie: OosterschelderegioBehandelfase: nog geen of 1 gesprek gehadTestdatum: 23-02-2010------------------------------------OQ45-score: 75. Sub-schalesSymptom Distress: 51 This score is highInterpersonal relations: 10 This score is normal Sociale Rol: 14 This score is above averageCritical ItemsSuicide: Yes Substance abuse: No Violaence: YesEr is een hoge factorlading opDepression/anxiety: YesFeeling of Well-being: YesImpact of Stress: Yes

  12. “the psychological thermometer” 180 • Gegevens van patiënteGeboortedatum: 1978 Geslacht: VrouwBehandellocatie: OosterschelderegioBehandelfase: nog geen of 1 gesprek gehadTestdatum: 23-02-2010------------------------------------OQ45-score: 75. .Sub-schalesSymptom distress: 51: H Interpersonal relations: 10 : N Social Roles: 14 :above ACritical ItemsSuicide: yes Substance abuse: No Violence: Yes Er is een hoge factorlading opDepression/anxiety: YesFeeling of Well-being: YesImpact of Stress: Yes 87 55 0

  13. Your psychological temperature 180 • Gegevens van patiënteGeboortedatum: 1978 Geslacht: VrouwBehandellocatie: OosterschelderegioBehandelfase: nog geen of 1 gesprek gehadTestdatum: 23-02-2010------------------------------------OQ45-score: 75. Deze score is hoog.Sub-schalenSymptom distress: 51 H. Interpersonal relations: 10 N. Social Roles: 14 above ACritical ItemsSuicide: Yes Substnce abuse: No Violence: YesEr is een hoge factorlading opDepression/anxiety: YesFeeling of Well-being: YesImpact of Stress: Yes 87 75 55 0

  14. Step I, Sub-step 1:Restoring overview • Dialogue • Patient’s report • Measurement Manageable bits

  15. Sd – Ci - Cs - outline

  16. Sd – Ci - Cs - outline

  17. Step I, substep 2:connection Sd = Ci x Cs • Descriptive diagnosis • Emphasis on: Cs

  18. Step I, Sub-step 2example Sd = Ci x Cs • Depression = (too) much burden x doom-mongering • Panic D = loss x doubtfulness • Panic D = > distress x extreme cautious

  19. Trait and Character Inventory

  20. Step I, Sub-step 3:Targets; Pathway • Sd: self- control techniques; medication • Ci: support; relationship(s); sharing the burden • Cs: improving coping style; equilibrium; prototypes; metaphor

  21. Measurement 1.:evaluate and (if necessary) adjust

  22. Step II: Behaviour Change

  23. Step II: Behaviour Change • Social learning • Cognitive restructuring • Behaviour experiments

  24. Step II, Sub-step 4: Habits and alternatives Sd = Ci x Cs

  25. Step II, Sub-step 4: Habits and alternatives Sd = Ci x Cs

  26. Coping style • Habits • Dimensional • Position on an equilibrium too little----------------------------------too much

  27. Cs: equilibrium • Egoist-----------------------------------Altruist • Avoidant--------------------------------Impulsive • Pessimist------------------------------Optimist • Extravert-------------------------------Introvert

  28. Cs: equilibrium: other examples • Richard-----------------------------------Hyacinth • Manuel------------------------------------Basil • Florance Nightingale------------------Madonna • Throwing in the towel ------- Man of action

  29. Habits and alternatives: intermediates • Avoidant—cautious—steady—carefree—enthousiatic—Impulsive. • Shy—introvert—single—normal—cooperative—extravert—Sociable. • Obsessive—stubborn—serious—steady—flexible—Indolent.

  30. Step II, sub step 5:Behaviour change by imitationThe use of prototypes and metaphors • Too much “Manuel – like” behaviour (Fawlty Towers) • Too much “Richard”, too little “Hyacinth or Onslow” • Too much Florance N, too little Madonna • From: “always yes, of course” to: “yes, but” • From Florance N. to: “in between” • From: “absolute single” to: “ a little cooperation” • From: throwing in the towel to: deliberated action • From: bull in China shop to: deliberated action

  31. The power of metaphor / prototype • Multiple access (verbal; imaginative; interactive; activity) • Differs perception and reality (activates distance) • Humor (nonblaming) • Examples for change (perspective) • Speedy recall

  32. Behaviour change by imitation:techniques • Equilibrium and sociogram “if you imagine……(family, friends, collegues, etc), how are they divided on...” • Equilibrium and prototypes “Who among your collegues, acts different than Florance Nightingale, without going overboard…?”

  33. Equilibrium and techniques • Observing (oneself, other people, exceptions, effects) • Reflecting • Imitating • Experimenting / role playing • Cognitions

  34. Step II, sub step 6:The interconnection between behaviour andCognitions / automatic ideas • Simple examples: (a sudden noise at night). • Burglar or cat? (action guided by perspective) • How would Florance N. react / think about that noise? How would Madonna do? Or …? • Simple role playing in the office.

  35. Cognitions and your equilibrium • Stimulate meta cognitive activity: if it is your habit to act like, and you realise that …… what do you think that your habitual thoughts will be about ………. • Introduce The Beck outline

  36. Step II, sub step 7gedachten uitdagen

  37. measurement 2:Evaluate and what next

  38. Step III, sub step 8Termination and relapse prevention • Reminders • Peers • Symptom = signal • Time out • Instruction booklet

  39. Evidences

  40. Evidence 1.Van Orden et al (2009) Psychiatric Practice • 165 patients, different diagnoses • Brief therapy (BT) at GP’s office versus CAU in second line • Symptom reduction: No difference • Quality of life: No difference • Satisfaction: No difference • Needed amount of sessions: BT: 30% less. • % Relapse: not available yet

  41. Evidence 2Van Straten et al. (2006, Br. Journ. Psych.; 2006, Acta Ps. Scandinavica) • 702 patients: Anxiety / mood disorders • Random: BT – CBT or CAU • Results: same as: Van Orden • Relapse (18-24 m): CAU >> CBT > BT

  42. Evidence 3Heene et al,

  43. Heene et al 2011

  44. Severity at start

  45. OQ-45.2-Total Means OQ_Total_group 100,00 low mild high very high 80,00 60,00 40,00 1 2 3 time

  46. Conclusion • Guided/shared exploration and planning + • Guided SL, BE and CR + • Low threshold • (at least) same result but in shorter time

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