Counseling of depression in primary care

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Counseling of depression in primary
care?????????????

• Dr. Alan Syed ?????
• ???????????
• ????????????
• ????????????
• ??????????????

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Evidence based counseling

• Cochrane Database Systemic Review (2007)
• Psychosocial interventions by GP
• Main results There is good evidence that
  problem-solving treatment by general
  practitioners is effective for major
  depression.??????
• Level 1 evidence that problem solving treatment
  by a GP is no less effective than antidepressant
  treatment on depression, psychological symptoms
  and social functioning.
• Caution 2 studies, conducted by same research
  team, 30 to 40 patients group, were treated by
  experienced and highly trained research GPs,
  which limits the translation to general practice.
  
• Huibers M, Beueskens A, Blejenberg G, Schayck Cp
  V. Psychosocial interventions by general
  practitioners. Cochrane Database Sys Rev. 2007
  Jul 183CD003494.

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Function of counseling

• Central function of counseling is to help clients
  to recognize their own strengths ??and clarify
  what kind of person they want to be (Corey, G.)
• Help clients to learn to take actions for solving
  problems of living and grow psychologically
  (David Ho et al)?????????????????

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Goals in primary care setting

• Supportive counseling
• Reattribution
• Psychoeducation
• Crisis intervention
• Problem solving
• Symptoms amelioration anxiety, depression, anger
  
• Enabling the person to
• Better utilize and develop his/her ability and
  resources????
• Enhance self esteem, self confidence and self
  discipline????
• Make better choices ?????
• Be more responsible for himself/ herself
• Have better self understanding and acquire more
  peace within
• Build up harmonious and meaningful relationship
  with others

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Some beliefs about counseling(Based on Satir
Model)

• Everybody has the ability to change for
  betterment
• Change is possible, and HOPE is the significant
  factor for change???????,?????????
• We cannot change the past, but we can change its
  impact on us????????,????????????
• We all have internal resources (strength) we need
  to cope successfully and grow
• The problem is not the focus in counseling,
  helping the person to cope better with the
  problem is the problem( find the ability and
  strength)
• The problem of an individual needs to be
  understood and resolved in a systemic perspective.

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Counseling theories

• Understanding human being and its function
• Human functioning is influenced by
• Physical, mental, emotional , social, cultural,
  political and spiritual dimensions
• Balanced integration of physical, emotional,
  mental, existential and spiritual level of
  consciousness (meaning of life) to achieve an
  optimal health.
• A holistic approach healing at different levels

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Counseling of depression

• All approaches basically to help the patient to
  change thinking and behaviors
• Frequent used approaches
• Family system therapy
• Person Centered Therapy
• Existential therapy
• Reality therapy
• Cognitive behavioral techniques
• Mutimodal therapy

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The counseling process overview

• 1. Connecting
• -relationship building
• 2.Assessing
• - the presenting problem and its impact on the
  person
• 3.Intervening
• Goal setting
• facilitating change
• 4.Consolidating
• - Anchor change closure ????????!?

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Therapeutic tool- Satir Model
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Some other therapeutic toolsBased on Choice
theory ( New reality Therapy)

• Three Major aspects of Choice Theory
• Basic needs
• Quality World
• Total Behavior
• Basic Needs (self worth)
• Survival ??
• Love and belonging ????
• Power ??
• Freedom ??
• Fun ??
• The Quality World
• In one quality world, one creates and stores
  pictures of
• 1) the people we most want to be with
• 2) the things we most want to own or experience
• 3) the ideas or systems of belief that govern
  most of our behaviors

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A Case to shareThe patients presenting problem

• Mrs. Lam presented with right jaw pain and
  numbness of the right face for few days. She
  attributed to fish poisoning. She was worried
  that she had a serious problem which required
  surgery for treatment.
• She had symptoms of depression
• poor appetite and weight loss of 5 pounds.
• Insomnia with early morning waking for two weeks
• Depressed mood for a month
• Feel anxious with tightening of fists and
  clenching when she woke up in the morning. Guilty
  feeling after she hit her son when she was upset.
  Loss of interest.
• She has excessive worries to her health, her
  sons education. Her husband was out of job
  recently and she worried about the mortgage.

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Famliy genogram
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Background history

• Mrs. Lam, 34 years old, married, a school teacher
  with two sons.
• She had depressed mood for a month because of the
  poor relationship with her husband, they did not
  have sex for 6 months.(interpersonal problem)
• She remembered her husband did not go to the
  hospital immediately when Simon was born, she
  rang him up and he told her that he was playing
  video games at home.(living in the past)
• Last year her father in-law gave her a lot of
  pressure when Simon applied for primary school
  admission, he only allowed Simon to go to the La
  Salle College primary school. (constrictive
  rules)
• She herself wanted Simon to have good school
  results, she was upset if he did not get high
  marks at examinations. She would hit him when she
  got irritable from teaching him. (unrealistic
  expectation)

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Problems identified

• Dysfunctional beliefs
• Her belief was that if Simon did not have good
  school results, she would be a bad mother.
• Unrealistic expectations
• As a teacher in a special school for children
  with behavioral problems she expected the kids
  to learn like a normal child.
• She had a high level of frustration from her
  unrealistic expectations.
• She projected her frustration to Simon when she
  taught him at home.
• Interpersonal relationship
• For many years she blamed her husband for no
  action at anniversaries of their marriage.
• She remembered her husband did not go to the
  hospital immediately when Simon was born, she
  rang him up and he told her that he was playing
  video games at home.(memories of unhappy
  experience)
• Communication problem to anger and violence
• Recently she wanted a divorce because she felt
  demoralized when she took her mother in-law to
  massage and paid for the fee but her husband did
  not appreciate what she did. She asked him back
  for the money, he refused and they had a fight.
• Stressors
• Her husband, an I.T. manager, was redundant from
  his company recently.

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Biopsychosocial model

• Biological
• The etiology of the depression included genetic
  and biological factor, the cause was deficiency
  in neurotransmitters in the brain.
• Psychological
• The somatic presentation is a means of escaping
  from problems or a psychological response or
  manifestation of emotional stress.
• The problem included cognitive, maladaptive
  coping behavior and interpersonal relationship.
• Social
• Mr. Lam lost his job,
• There is a financial burden
• and she did not have any confide to share her
  feelings apart from her elder sister with whom
  she has a better relationship
• all these contributed to her emotional problem.

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Interpretation with Family context

• Family as a system
• In this hierarchical family, there are
  constrictive rules.
• Grandpa must dominate, especially over his
  grandsons education,
• differences are bad and change is to be
  resisted gave Mrs. Lam a lot of stress because
  of restricting freedom of expression.
• The family had a closed system in which everyone
  is supposed to have the same opinions, feelings,
  and desires whether or not this is true.
• Members in this hierarchical system lack
  tolerance for difference and uniqueness which
  cause emotional and behavioral disturbance.

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Family dynamics

• (A) Family structure
• An extended family
• (B) Family function
• The family was dysfunction
• when Simon was born,
• at application for Simons primary school
  education
• and when Mr. Lam lost his job.
• There is disturbance in role, status, power, or
  unhappy events at certain stage of family life
  cycle.
• The dysfunctions arise from poor ability to cope
  and solve problems.

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Dysfunctional communication (Satir Model)

• With constriction of the Self by restrictive
  rules, unrealistic expectations and inappropriate
  roles comes defensive communication into four
  styles of survival coping stances placating,
  blaming, being super-reasonable, and irrelevant.
  
• The patient used placating mode caused her to
  repress her anger towards her father- in -law and
  manifest physical symptoms.
• She used the blaming mode towards her husband.

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Family dysfunction with the metaphor of the
personal iceberg

• Mr. Lam lost his job hence his role changed.
  Instead of being a bread winner, he did the
  domestic work, took children to school. His
  status lost, perceived the grief with low self
  esteem therefore he did not interact with his
  wife.
• Simons learned from the family triad, through his
  parent arguments, he perceived himself as
  useless, valued with low self esteem. He behaved
  poorly at school because he yearned for his
  parents love, they help him with revision
  together.
• Mrs. Lam was not happy that her husband did not
  come to hospital early (unmet expectation). She
  perceived her husband did not love her, valued
  with low self esteem. She had the feeling of
  grief, entered sick role (behavior) with
  emotional disorder.

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What have been done apart from the usual care?

• Management (usual care)
• Exclude organic course
• By detailed history, physical examination, and
  investigations including ESR, thyroid function
  test.
• Management of depressive disorder
• Prescribing SSRI.

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Counseling for emotional problems

• To establish a therapeutic relationship
• To develop rapport with genuineness,
  unconditional positive regard and respect,
  empathic understanding and trust, facilitate
  communication by active listening, picking verbal
  and non verbal cues.
• It is the therapists attitude and belief in the
  inner resources of the client that create the
  therapeutic climate for growth.
• BOZARTH, J. D., Zimring, F.M. Tausch, R.(2002).
  Client-centered therapy The evolution of a
  revolution. In D. J. Cain, J. Seeman, (Eds),
  Humanistic psychotherapies Handbook of research
  and practice (pp147-188). Washington, DC
  American Psychological Association.

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Assessment

• With the understanding of the patients life
  cycle and family dynamics, explore the patients
  current emotional status (worries and concern).
• Identify contributing factors for the emotional
  disturbance by exploring
• the present family situation, work environment,
  sexual behavior and financial situation.
• To establish a shared understanding of the
  problem and contributing factors with the
  personal iceberg metaphor of the Satir model
  including feeling ,perception, expectations,
  yearning, behavior, coping reassure her that her
  symptoms are not organic and it represents an
  emotional problem.

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Exploring thepersonal iceberg metaphor in the
Satir model

• Exploring the behavior
• Doctor What behavior do you want to change?
• Lam I would like to stop scolding my husband or
  hit him when he did not do what I expected, for
  example, watch over our sons homework
• Exploring feelings
• Doctor What feelings do you experienced when
  that happened?
• Lam I feel angry.
• Exploring feelings about feelings
• Doctor How do you feel about feeling anger with
  your husband?
• Mrs. Lam I feel I am useless.
• Exploring perceptions
• Doctor What was your interpretation that your
  husband did not do what you expected?
• Lam He did not love me anymore.
• Exploring meaning
• Doctor What meaning are you giving to this
  situation to mean to you?
• Lam He does not care about my feelings.
• Exploring beliefs
• Doctor Do you believe you have a choice in this
  situation?
• Lam I believed so.

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Exploring the following

• Impact
• Past attempts to solve problems
• Crisis
• Relationship with family
• Resources and limitations
• Capacity and readiness to change
• Frame of reference-FOO
• Supporting network inside and outside family

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Intervention-Goal setting

• Use a collaborative approach negotiating a common
  realistic goal.
• The goal of counseling (the Satir model) is to
  improve self esteem which is the basic element in
  dysfunctional family behaviors.

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Counseling techniques used

• (1) Cognitive therapy
• (2) Behavioral modification
• (3) Information giving
• (4) Stress management
• (5) Psychoeducation
• (6) Communication skill training
• (7) Satir model (microskills)
• (8) Coping skills training
• (9) Choice theory

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(1)Cognitive restructuring

• Identify automatic thoughts
• Challenge automatic thoughts and perceptions and
  dysfunctional behaviors by socratic questioning
• Replacing automatic negative thoughts with
  rational and useful thoughts

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(2) Behavioral modification

• Learn adaptive coping skills,
• find resources and strength as each person
  contains all the resources one needs for growth
  and healthy functioning.
• Teach the patient to avoid using maladaptive
  survival stance coping skills including placating
  and blaming,
• use skills to improve awareness, acceptance of
  our own feelings which would promote high self
  esteem in a harmonious way with the aim to become
  congruent.
• Activity scheduling-Focus on pleasant activities,
  rate the sense of achievement, use of dairy to
  record accomplished activities

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(3) Information giving

• Change is possible and we have choices.
• Hope was a key source of resources for
  facilitating change.
• Problem is not a problem , coping is the problem

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(4) Stress management

• Identify the source of stress
• Previous coping strategies
• relaxation exercise
• assertive skills
• Relaxation techniques
• with controlled breathing,
• progressive muscle relaxation
• guided imagery

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(5) Psychoeducation

• Doctor Given your history of family stress, your
  symptoms were of an emotional basis, accordingly
  the DSMIV, it is a major depressive episode,
  caused by a deficiency of neurotransmitter in the
  brain which could be corrected by SSRI.
• The interpersonal problems complicated your
  illness, counseling or psychotherapy help you to
  see the relationship and interactions between
  thoughts, feelings and behavior and the
  physiological symptoms.

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(6) communication skill training

• Communication is to relationships what breath is
  to life, so schedule a time each day to talk to
  each other.
• Tell your husband what you want I wish that
  you could ring me up during the day.
• Avoid Deadly habits that destroy relationship
• Criticizing ??
• Blaming ??
• Complaining ??
• Nagging ??
• Threatening ??
• Punishing ??
• Bribing or Rewarding to control ?????????
• Learn caring habits that nurture relationship
• Supporting ??
• Encouraging ??
• Listening ??
• Accepting ??
• Trusting ??

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(7) Microskills (Satir Model)??????

• Make contact
• Reaching out by eyes contact, facial expression
  (connect- log-on)
• Attending, active listening
• Observe the posture, eyes, facial expression
• Observe verbal and non verbal cues

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Microskills-Validating to create a sense of safety

• Engendering hope
• Mrs. Lam He hit me, I wanted a divorce
• Doctor Although it feels pretty hopeless now, I
  see new possibilities for you, there are other
  alternatives we can explore. ???????????,?????????
  ?,????????
• Affirming resources
• Doctor Are you aware of the strength and courage
  you talked about your problems today? I remind
  once again of your capacity to change.??????????,?
  ???????????????
• Normalizing
• Doctor All couples will go though disappointment
  after marriage.??????????????????

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Other microskills

• Reflection of feelings
• Doctor From what you are saying, I am hearing
  that you feel pain about what is happening in
  your marriage??????,???????????????
• Reframing
• Doctor I see that the members of this family are
  wanting good things to happen but not knowing how
  to make that happen.????????????????????,?????????

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MicroskillsDefusing Blaming and Guide to change

• Doctor Now that you have put an expectation on
  your spouse that does not fit, are you willing to
  let go of that??????????????
• Doctor On reexamination of you expectation and
  beliefs, what changes do you want to
  make???????,???????
• Lam I would like to stop making negative
  generalizations about my husband. I would like to
  stick to the issue at hand and ask for help in a
  non-reactive manner. ???????????????????,?????????
  ???????????

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Microskills Shifting from content to process

• P My father in law is driving me crazy on
  choosing a school for Simon.
• D How have you two dealt with other
  differences??????????????????
• P What other ways does Simon aggravates you?
• Simon is out of control. He did not show any
  obedience.
• D What do you mean by obedience?
• D How did people show obedience in your family
  when you were growing up?

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Microskills Identify the Dysfunctional process

• What I see is that, Mrs. Lam, you are living the
  life of a victim, blaming others especially your
  husband and looking backward instead of forward.
• With the negative aspects of your life, which
  you did by dwelling on your major symptoms
  depression, anxiety, inability to sleep, and
  other psychosomatic symptoms.

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Cognitive restructuring-modify the blocked
resources

• When Mrs. Lam resources were being blocked by
  restrictive rules, inappropriate roles or
  unrealistic expectations, cognitive restructuring
  would modify these blocks.

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Microskills Challenging interpretations by
cognitive restructuring

• Doctor Could you think of other possibilities
  that your husband did not go to the hospital
  immediately after Simon was born?
• Mrs. Lam He could be afraid of the hospital
  environment he could have anxiety when it was
  the first time he became a father he worked at
  home to meet a deadline, he just finished and was
  playing with the video game.

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Microskills Cognitive restructuring on
irrational belief

• I must to follow the rules of the family
  otherwise I am unlovable.
• I prefer to follow the rules of the family ,if
  not I am still a lovable person
• Simon must do well at school otherwise I am a
  bad mother
• I prefer Simon to have good results, I have done
  my best to be a good mother.

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Microskills Freeing the SelfModifying
restrictive rules

• Mrs. Lam I must obey grandpa rules
• Doctor You should say I can choose how I want
  to meet the needs of my family, sometimes I can
  choose my childrens needs and sometimes I can
  choose my needs

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Microskills Modifying unrealistic expectations

• I attempted to elicit the unspoken expectations
  for her parenting, knowing that many conflicts
  originated at the level of expectations.
• Recognizing how vulnerable children are to being
  objects of their parents projections with the
  following parent child relationship
• Make the parent feel worthy, by achieving or
  performing
• Want and like the same thing the parent does
• Want to do what the parent wants
• Parent the parents
• Be a diversion so that their martial conflict can
  be denied
• Lam These were the reasons I got frustrated with
  teaching Simon.

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Microskills Broaden perspectives

• When yearnings are not met and people are
  carrying dysfunctional rules, roles or
  expectations, they will have limited
  perspectives.
• I let her know that perceptions are the product
  of their own process, not external events.

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Teaching new behaviors- maladaptive coping gives
low self esteem

• Placating disregard our own feelings of worth and
  say yes to everything, denies self respect and
  give people the message that we are not
  important.
• Blaming is an incongruent way of reflecting
  constrictive rules, we should stand up for
  ourselves, not accept excuses, inconvenience or
  abuse from anyone. To blame is to discount others.

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Microskills Treasure huntAppreciate partner at
least once a day

• Detective hat- make sense
• Golden key- new possibilities
• Yes no medallion- boundary definitions
• Courage stick- overcome difficulties
• Wishing wand- provide energy for overcoming great
  challenges
• Wisdom Box- guided towards wholeness/humanistic
• Heart (Jean Mclandon)- essential for congruence

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(8) Coping skills training

• Assertive Training
• Focused on her negative self statement, because
  she did not think she had the right to ask what
  she wanted,
• She succeeded in saying no to her father-in-law
  demand and expressed her viewpoint.
• Use verbal, vocal and body message sub-skills
• I statement and say No
• Speak in a calm, firm voice, good eye contact,
  avoid threatening gestures- finger pointing
• Via modeling and role-playing

• Increase social interaction
• Identifying factors that are contributing to low
  social interaction
• For example, getting into habit of doing things
  alone
• Feeling uncomfortable due to few social skills
• Deciding on activities that needed to be
  increased calling friends to suggest getting
  together
• Decreased watching television- increase social
  interaction
• Graded task assignment
• Self reward
• Decreasing rumination and excessive self focus

• Problem solving skills
• Doctor You could identity the problem, list all
  possible solutions, pro and cons of each
  possibility, choose best strategies, set a plan
  for implementation and evaluate.
• Lam For the mortgage, I could re-schedule the
  mortgage or sell the apartment and rent a house
  for the time being.

• Anger management
• Doctor Anger is a result of threat, fear or
  unmet expectation. You should aware, acknowledge,
  accept, own, control and express your anger in an
  appropriate manner.
• Acceptance of others.
• Go away from the scene when you have signals of
  anger.
• Think of other possibilities positively.

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(9)New Reality therapy?????- based on Choice
theory????

• What do you want?
• If what you are doing now does not get you what
  you want, do you want to change?
• Use three major aspects of choice theory to
  promote change
• Identify Basic Needs
• Discovering clients Quality world
• Help client understand she is choosing the Total
  behavior that are the symptoms
• Information
• Better choice is available
• Things do not just happen
• Plan to make better choices
• Take much more effective control of her life

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Choice Theory (New reality therapy)

• Lam I feel depressed much of the time, anxious
  at night and overcome by panic attacks
• Doctor I let her know that I was more interested
  in what she is doing and thinking because these
  are the components that can be directly changed
• Her depressing is the feeling part of her choice,
  she can take a different action which is likely
  to change her depressing experience

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You can only control yourself

• She come to realize that she does not have to be
  a victim of her past unless she choose to be and
  she had reharshed her misery enough.
• She learned that most of her symptoms and
  avoidance keep her from what she want.
• She realize that she has little control over
  changing others but has great deal of control
  over what she can do now.

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Anchoring Change

• Last visit-Experiencing greater self esteem
• Her eyes are bright and lively.
• Face relaxed
• Relaxed jaw
• Smiling- Our family went to church together
  then we went to the beach together.
• Consolidating the change
• KISS
• Keep
• Improve
• Stop- deadly habits
• Start- start caring habits
• Anchoring change
• Anchoring the change at the whole person level,
  not just behavioral or perceptual change
• Positively reinforce the change by verbal and
  non- verbal techniques
• how wonderful that you two can now be with each
  other in this new way.

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How would you follow up this patient in the
future?

• Anchor change
• Promote congruent living
• Mutimodal approach- BASIC-ID
• Encouragement/ empowerment
• See husband for couple therapy
• CB strategy/ CBT
• Refer to psychiatrist
• Refer to counseling specialist
• Refer to psychologist
• Refer to family mediation specialist

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Mutimodal therapy

• Comprehensive, systematic, holistic approach to
  behavior therapy
• Technical Eclecticism
• Assessing the BASIC ID
• Lazarus, A.A. (2000). Mutimodal strategies with
  adults. In J. Carlson L. Sperry (Eds.), Brief
  therapy with individuals and couples (p106-124).
  Phoenix Zeig Tucker.
• A major premise of mutimodal therapy is that
  breath is often more important than depth.
• The more coping responses a client learns in
  therapy, the less are the chances of relapse.
• Lazarus, A.A.(1996). Some reflections after 40
  years of trying to be an effective
  psychotherapist. Psychotherapy, 33(1), 142-145.
• Lazarus A. A. (2000). Mutimodal therapy. In R.
  Corsini D. Wedding(Eds.), Current
  psychotherapies (6th ed., pp340-374). Itasca, IL
  F.E. Peacock.

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Mutimodal approach

• Behavior
• Refers overt behaviors- observable and
  measurable
• What would you like to change?
• What would you like to stop and start doing?
• What are some of your main strengths?
• What specific behaviors keep you from getting
  what you want?
• Affect
• What makes you laugh?
• What makes you cry?
• What emotions are problematic to you?
• Sensations
• Do you suffer from unpleasant sensations?
• Imagery- the way we picture ourselves
• How do you see yourself now?
• How would you like to able to see yourself in the
  future?
• Cognition
• What are the negative things you say to yourself?

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Long term goal

• Congruent living ????
• To communicate clearly
• cooperate vs compete
• empower vs subjugate
• use authority to guide and accomplish
• to love ,value and respect themselves fully
• personally and socially responsible
• to use problems as challenges and opportunities
  for creative solutions

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• Thank you

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