Taking ERP From the Treatment Manual to Your Patients: A Guide to Application - Alliance of Chicago
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Taking ERP From the Treatment
Manual to Your Patients: A Guide to
Application
Patrick B. McGrath, Ph.D.
A.V.P., Residential Services, AMITA Behavioral Medicine
Clinical Director, AMITA Health Center for Anxiety and Obsessive Compulsive
Disorders
Co-Director, AMITA Health School Anxiety / School Refusal Program
President, Anxiety Centers of Illinois
Member, Scientific Advisory Board, International OCD Foundation
President, OCD-Midwest
Contact and Warning For a copy of this: Patrick.McGrath@amitahealth.org • Disclaimer: Real examples and the language used by clients will be used. If easily offended, you have been warned!
The Dangers of a Lack of Empirical
Validation
• Facilitated Communication
• Re-Birthing Therapy
• Conversion TherapyEmpirically Validated Treatments • Ethical implications. • Insurance payments. • Updates in the literature – If a surgeon still used a surgical procedure that was popular 30 years ago when there have been advances made in that same procedure, we would sue them.
Cognitive Behavioral Therapy is…
• Active, problem-focused.
• Focused on Emotions/Feelings.
• Focused on Thoughts.
• Focused on Behaviors.
• Client-centered, Couple-centered, Family-
Centered; collaborative.
• Present-centered.
• The basis of all therapy ever done:
– All work is based on S-R model.Basic Assumptions… • Effective therapy requires specific goals. • The counselor is active, directive, and prescriptive. • The counselor / patient / couple / family relationship is important, but not all that is needed for change. • Based on research and empirical data.
How it works • The focus is on how one thinks about a situation and how that thinking helps or hinders the progress in their lives. A CBT therapist designs behavioral programs to assist the person in challenging those thoughts and developing new ones. New behaviors are designed to assist a person in challenging their thoughts and the emotions.
Thoughts Behaviors
FeelingsThoughts Behaviors
Feelings
DepressionThoughts Behaviors
Feelings
Depression
ActionThoughts Behaviors
Feelings
Depression
ActionContext and Fear Learning
• Insights from research on fear learning and
extinction.
– 1. Fear acquisition is unconditional or context-
independent.
– 2. Fear extinction (“learned safety”) is conditional or
context-dependent.
– 3. We don’t “unlearn” a fear, we acquire new
learning that competes with previous learning.
– 4. The current context determines our perception of
danger or safety.
– 5. The central task in CBT is to create context-
independent learned safety.
© McGrath, 2009
© Brett Deacon, 2006Cognitive Behavioral Model for the
Treatment of Anxiety Disorders:
Maintenance
Fear Stimulus
Misinterpretation of Threat
Anxiety
Safety Seeking Behavior
Absence of Corrective ExperienceCBT Model of Anxiety:
OCD Example
Intrusive thoughts about harming a child.
Fear Stimulus
Misinterpretation of threat “Having these thoughts will make me harm
my child.”
Anxiety Anxiety..
Refuses to be near a child without another
adult present, avoids sharp objects,
Safety Seeking Behavior asks wife for reassurance, replaces
“bad” thoughts with “good” thoughts
Does not learn that violent thoughts do not
Absence of Corrective equal violent behavior. Maintains the
Experience avoidant coping.BEHAVIOR THERAPY (BT)
• Exposure and Ritual (Response)
Prevention (ERP) is the key element.
– Meyer (1966).
– Based on the principle of habituation.
– Habituation is the decrease in anxiety
experienced with the passage of time.BT (continued)
• Exposure is placing an individual in feared
situations (targets the obsessions).
– Needs to be prolonged enough to lead to
within trial habituation (at least 50% reduction
in anxiety).
– Needs to be repetitive enough to lead to
between trial habituation (until causes minimal
to no anxiety between trials).
– Needs to be graduated (increases
compliance).Life With an Anxiety Disorder
Overcoming Anxiety with Exposure
Exposure Rules • Never have a patient do something that you would not do yourself. • Do not have them do anything dangerous. • Do not do an exposure only once as a part of treatment (May be limited in a session to only do one time. However, reassign for homework.). • Do not just do exposures for a set amount of time – remain in the exposure until the anxiety level has decreased by at least half of the starting value.
Hierarchies • The basis of all ERP is the hierarchy that the patient develops. • Have them list all of their fears and the areas that they want to work on in therapy. • Rank order those items from lowest to highest. Can say “If you were told to do all of these things right now, which would be the easiest to the hardest?” • Goal is to work your way up the hierarchy gradually - not to scare the patient away from future sessions.
BT (continued)
• Response Prevention is blocking the
typical response or ritual before, during,
and after exposure so habituation can take
place (targets compulsions).
– Replace the safety seeking with habituation or
belief change as a way of controlling anxiety.
– Allows your patient to learn that their feared
consequences do no happen, or if they do,
they can handle them.Avoidant Coping • Based on misappraisal of threat. • Intention is to avoid fear stimulus or the danger it signals. • Precludes adequate exposure to fear stimulus. • Does not allow a disconfirmation of the threat misappraisal.
Reassurance Seeking • Asking others for reassurance lets you off the hook – if something goes wrong, you are not responsible, because you would have never done it if the other person had said that it might be dangerous. • The more reassurance you get, the more you want in the future. Each day, a little bit more is needed to get the same effect as the day before. Families are huge offenders in this area!!
Distraction
• Making it look like you are doing your
feared behavior but not really doing it.
– Many people fly but still fear flying – this is
because they distract and do not really
experience the flight – they cry, pray, drink,
take PRN medications, and attribute their safe
landing to all of those actions and not to the
fact that they could have handled the flight on
their own.Safety Seeking • People go for short term relief, at a long term cost. • Therapeutic anxiety prevention relies on short term discomfort with a person waiting that pain out until it goes away on its own. • They realize that there are not long term negative effects of suffering through the exposure.
Short Term / Long Term • Doing what you can do to feel good right now is often not the best option in the long run. – Drug Use. – Stopping Chemo Therapy. • Long term changes are difficult to work toward due to the lack of immediate gratification that we want when we are feeling anxious.
Safety Seeking Behaviors • Avoidance, Reassurance seeking, and Distraction are often referred to as SAFETY SEEKING BEHAVIORS. • Can be both internal and external. • The non-occurrence of catastrophe is attributed to safety behaviors rather than to the fact that catastrophe would probably not have occurred anyway. • Safety Seeking Behaviors interfere with the disconfirmation of erroneous beliefs, thereby maintaining anxiety disorders.
Four Basic Fears
Threats to the integrity of:
*Physical Status.
*Mental Status.
*Social Status.
*Spiritual Status.Common Distortions
• Severity.
– It will be the worst thing in the world and I will
die.
• Probability.
– It will definitely happen, no question.
• Efficacy.
– I will not be able to handle it.
• Possibility versus Probability is important.An Integrative Cognitive-
Behavioral Model
• Anxiety disorders are caused by erroneous beliefs
about the dangerousness or meaning of feared
stimuli.
• Anxiety disorders are exacerbated by attention
toward threat which increases the perception of
threat cues.
• Anxiety disorders persist because safety behaviors
prevent the disconfirmation of erroneous beliefs.
• Use this framework to guide assessment, case
conceptualization, and treatment planning.
© McGrath, 2009
© Brett Deacon, 2006So, how do we DO this?
• Do you need CBT?
– If you have anxiety or depression, then yes,
why not use the most evidence based
treatment available to you?
• Can CBT assist outside of a psych based
office?
– Of course. More and more offices are
including CBT specialists into their offices to
assist in teaching skills to patients to manage
anxiety and depression and to decrease
reliance on medications.What makes AMITA Health
Alexian Brothers Behavioral
Health Hospital Different?
• 27/7/365 Behavioral Health ER – our
ACCESS department. Anyone walking in
will get a free Level of Care screen to
determine what level of care might best
suit them at ABBHH. Levels of care are
Inpatient, Residential, Partial Hospital
Program, Intensive Outpatient Program,
and Individual Therapy.Link with AMITA • I have brought our grids of all of the different levels of care, with our Call Center number on it. • Check out our Professional Education Series – we are one of the largest Professional Education providers in Illinois. • Speakers Bureau – we can come and do talks with your group.
Don’t Try Harder, Try Different • Should is not a helpful word. • Can’t versus won’t. • Practice does not make perfect, it makes routine. • Control is an illusion. • Specialness. • Everything in the world is neutral. • All that we have are perceptions or interpretations.
Books by Dr. McGrath
Readings
• Don’t Try Harder, Try Different (McGrath; Stress
Management)
• The OCD Answer Book (McGrath; OCD)
• Feeling Good (Burns: Depression)
• Dying of Embarrassment (Markway, Carmin, Pollard, & Flynn,
Social Anxiety)
• An End to Panic (Zuercher-White; \Panic Disorder)
• School Refusal Behavior in Youth: A
Functional Approach to Assessment and
Treatment (Kearney; School Refusal)Contact • Patrick B. McGrath, Ph.D. • AMITA Health, Alexian Brothers Behavioral Health Hospital • 1650 Moon Lake Blvd. • Hoffman Estates, IL 60169 • 847 758 1625 • Patrick.McGrath@amitahealth.org
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