BC’s Mental Health and Addictions Journal Visions Vol. 6 No. 1 | 2009

Cognitive-Behavioural Therapy alternatives background approaches& 3 Editor’s Message Sarah Hamid-Balma 16 The LEAF Program: Peer-led group CBT Shelly Jones 4 The Time Is Now: Let’s improve access to CBT services in BC Mark Lau 18 The Cognitive-Behavioural Approach to Treating Individuals with Eating Disorders 6 Thinking Traps Ron Manley

6 CBT in Practice: Part science, part art 20 Metacognitive Training: Influencing Michelle Patterson schizophrenia treatment worldwide Todd Woodward 8 CBT: What is it? Nichole Fairbrother 21 CBT for Children and Youth in BC Gayle Read

23 CBT: Does it work well with the Chinese population in Vancouver? Mary Kam and Kelly Ng experiences perspectives& 10 Conversations with Myself Danielle Raymond

12 From Pain to PTSD: Running the gamut of CBT Lynda Marie Neilson

14 When Life’s Demands Take Their Toll: Changeways for depression Pat Merrett

bc partners visions

Seven provincial mental health and addictions non-profit Published quarterly, Visions is a nationally award-winning agencies are working together as the BC Partners for Men- journal which provides a forum for the voices of people tal Health and Addictions Information. We represent Anxiety living with a mental disorder or substance use problem, BC, British Columbia Schizophrenia Society, Canadian Men- their family and friends, and service providers in BC. tal Health Association’s BC Division, Centre for Addictions Visions is written by and for people who have used mental Research of BC, FORCE Society for Kids’ Mental Health, health or addictions services (also known as consumers), Jessie’s Hope Society and the Mood Disorders Associa- family and friends, mental health and addictions service tion of BC. By working together we have a greater ability providers, providers from various other sectors, and leaders to provide useful, accurate and good quality information on and decision-makers in the field. It creates a place where mental health, mental illness, substance use, and addictions many perspectives on mental health and addictions issues including how to prevent, recognize, treat and manage these can be heard. To that end, we invite readers’ comments and issues. Our goal is to help people feel empowered and im- concerns regarding the articles and opinions expressed in prove quality of life. this journal. The BC Partners are grateful to BC Mental Health and Addiction Services, an agency of the Provincial Health Services Authority, for providing financial support for the production of Visions

2 Visions Journal | Vol. 6 No. 1 | 2009 editor’s message

hen my anxiety disorder was finally diagnosed as an adult, I was on the list for 12 sessions of one-on-one CBT. I felt truly lucky Wwhen a spot opened up. regional programs CBT remains one of the hardest things I’ve ever done. It was so simple— and yet so hard. I had to do everything my intuition had been telling me not to do for more than 15 years. But intuition isn’t always trustworthy. You see, 25 Cognitive-Behavioural Therapy For Adults my mind and body had conspired together to find a way to cope all those with Mental Health Problems: Working to years—unhealthy ways to cope that didn’t really work well—but it was cop- improve access in BC ing nonetheless and those patterns of survival, well, are hard to break. I did Jamie Livingston, Mark Lau, Dolores it in baby steps, but the hardest part was bringing on the anxious feelings for Escudero, Eric Ochs, Gayle Read, Pam homework. My husband would spin me in a chair at home, nightly, until I got Whiting, Maureen Whittal, Chris Wilson nauseous. I would breathe through those brown plastic coffee stir sticks until 27 Help with Mild to Moderate Depression: I was gasping for air and then keep doing it for 10 more seconds. My family CBT-based self-management options couldn’t quite understand why I was doing things that made me feel bad, but Dan Bilsker I trusted the process. And it worked, and still does.

29 Taming Worry Dragons: Helping children My clinician used a manual to teach me the techniques. But I did all the and youth cope with anxiety work. There’s something both empowering and scary in healing yourself. Jane Garland and Noel Gregorowski Scary because success was up to me. Sometimes that power made me wonder if maybe I was to blame for my disorder since I could essentially get rid of it on 31 Bounce Back: Reclaim Your Health my own. But then I thought of people with physiotherapists. They are taught Kimberley McEwan strength and strengthening exercises to relieve and prevent pain, but we don’t doubt their pain or blame them. They just need tools to feel better. Like I did.

As I studied the dramatic pre- and post-scores of my CBT, I felt guilty too. There are tens of thousands of people on waitlists, or without any free CBT op- tion in their community. People who could transform their lives in a few short weeks and months. Our guest editor is right. If there were a cheap, effective, side-effect-free treatment for any physical illness, policy makers would be fall- ing over themselves to make it available and have MSP cover it. Thankfully, that’s starting to change, but still too slowly for my taste. Maybe the powers- that-be have a few thinking traps of their own they need to work on.

Sarah Hamid-Balma

Sarah is Visions Editor and Director of Public Education and Communications at the Canadian Mental Health Association’s BC Division. She also has personal experience with mental illness

subscriptions and contact us Tel: 1-800-661-2121 or 604-669-7600 advertising Mail: Visions Editor Fax: 604-688-3236 c/o 1200 - 1111 Melville Street Email: [email protected] Vancouver, BC V6E 3V6 Web: www.heretohelp.bc.ca If you have personal experience with mental health or sub- stance use problems as a user of services or as a fami- ly member, or provide mental health or addictions services editorial board | Representatives from each The opinions expressed in in the public or voluntary sector, and you reside in BC, BC Partners member agency this journal are those of you are entitled to receive Visions free of charge (one free editor | Sarah Hamid-Balma the writers and do not copy per agency address). You may also be receiving structural editor | Vicki McCullough necessarily reflect the Visions as a member of one of the seven provincial agencies views of the member editorial assistant | Stephanie Wilson that make up the BC Partners. For all others, subscriptions agencies of the BC are $25 (Cdn.) for four issues. Back issues are $7 for hard design/layout | Kailey Willetts Partners for Mental copies, or are freely available from our website. Contact us issn | 1490-2494 Health and Addictions to inquire about receiving, writing for, or advertising in the journal. Advertising rates and deadlines are also online. See Information or any of www.heretohelp.bc.ca/publications/visions. their branch offices

Visions Journal | Vol. 6 No. 1 | 2009 3 guest editorial

The Time Is Now Let’s improve access to CBT services in BC

ental health problems such as depression, better in the present and can be used to help prevent anxiety disorders and substance use issues future problems. take a huge personal, economic and social toll on British Columbians. For the one in five people who will ...but not everyone in BC can get CBT M 1 suffer from a mental illness in their lifetime, this means One of the biggest challenges with CBT is that not they may have problems in their family and/or work lives, everyone in BC who would like to get CBT can do so. along with the distress of their mental illness. Unfortunately, at the present time, there are very few Fortunately, there are treatments that can help peo- areas in BC that offer specialized CBT services. What ple who suffer from mental illness. For example, many does this mean for someone who could be helped by people find medication to be helpful. But there are CBT but can’t access it? those who find that the Let me give you an Mark A. Lau, medications don’t work. example by telling you PhD, RPsych Others cannot put up quickly about a client with the side effects of I treated for panic dis- Mark is a clinical medication. And many order early on in my psychologist, a research people simply prefer career. The good news scientist and Director talk therapy to deal with was that after about of the BC Cognitive their problems. 10 sessions of CBT, she Behaviour Therapy Research shows that was no longer having Network at BC Mental several talk therapies can panic attacks. At the Health and Addiction help people who suf- same time, she asked Services. He’s also fer from mental illness. me why she’d had to an Associate Professor Cognitive-behavioural suffer for eight years of Psychiatry at UBC and therapy (CBT) is the talk before she could get a a Founding Fellow of therapy with the greatest treatment that worked. the Academy of amount of evidence that Let’s pause for a Cognitive Therapy it works. Over the past moment to think about 25 years, hundreds of CBT is the talk therapy this. Could you ever im- research studies have agine a situation where shown CBT to be helpful with the greatest amount researchers had discov- * For more information in treating many different of evidence that it works ered a new effective on the BC CBT Network, mental disorders.2-3 It can cancer treatment see the article on p. 25 help in treating depres- but it wasn’t made sion, anxiety and problem substance use, to name available to all the cancer sufferers who needed it? Of just a few. These studies have also shown that, in course not. New effective treatments are made avail- many cases, CBT is as good as medication.4-5 In a few able to those who need them fairly quickly. Yet this is cases, it’s even better than medication.6 CBT has also not the case when it comes to CBT in BC and the rest been shown to cost less over the long term than med- of Canada. ications, in some cases.7-8 Making CBT equally available to everyone in BC What is CBT? A big part of the reason why patients can’t get CBT is CBT is a form of talk therapy that focuses on how a per- that there are too few mental health providers who’ve footnotes son’s thoughts about themselves, the world and oth- been properly trained in CBT to meet the demand. But visit heretohelp bc.ca/ ers relate to how they feel and how they act. In CBT, it doesn’t have to be this way. Over the last few years, publications/visions people learn to become aware of how their thoughts other countries around the world have started projects for Mark’s complete can affect how they feel and behave in the here and to improve access to CBT. For example, in the United footnotes or contact us now. They also learn skills and techniques to experi- Kingdom, the government has provided roughly $600 by phone, fax or e-mail ment with new ways of looking at things and/or new million to train 3,600 CBT therapists over the next (see page 3) ways of behaving. These changes can help us to feel three years.9

4 Visions Journal | Vol. 6 No. 1 | 2009 • letters

As a former frequent cannabis consumer, I—along with many of my former (some still) cannabis-consuming peers who I’ve bumped into these last dozen years or so—can attest to the permanent damage that marijuana can cause to the con- sumer’s body and mind.

Scientific proof of such potential damage? For one, there are the startling facts published in an article last September 17, in London’s Guardian newspaper; it was authored by professor of psychiatry at the Institute of Psychiatry and hospital consultant, Robin Murray: “In the mid-90s, a Dutch psychiatrist named Don Here in BC, there is hope for improving access to Lintzen, from the University Clinic in Amsterdam, noted that people with schizo- CBT. BC Mental Health & Addiction Services (BCMHAS), phrenia who consumed a lot of cannabis had a much worse outcome than those an agency of the Provincial Health Services Authority, who didn’t. This was confirmed by other studies, including a four-year follow-up at along with the BC provincial government and the five the Maudsley Hospital. Those who continued to smoke cannabis were three times regional health authorities, are working together to more likely to develop a chronic illness than those who did not consume the close the treatment gap. All recognize the need for im- drug,” Murray learned. “Why does cannabis exacerbate psychosis? In schizophre- proved quality and availability of CBT for mental health nia, the hallucinations result from an excess of a brain chemical called dopamine. and addictions across our province. All of the drugs that cause psychosis—amphetamines, cocaine and cannabis—in- Just last year, BCMHAS established the BC Cogni- crease the release of dopamine in the brain. In this way, they are distinct from tive Behaviour Therapy Network* to support system- illicit drugs such as heroin or morphine, which do not make psychosis worse.” wide efforts to increase the number of people who are trained to deliver CBT in BC. The goal of the CBT Net- If pro-pot people propose legalizing cannabis possession for practical reasons— work is that every person in BC will have equal access e.g., less pressure on already-overburdened law-enforcement and justice sys- to high-quality CBT no matter where they live. This will tems—that’s a clear and perhaps debatable motive; however, there’s simply way lead to better care and treatment for people with men- too much of the media-propagated misinformation out there implying—or tal health problems. outright declaring—to our impressionable youth that cannabis consumption is harmless. If you want to know more about CBT... In this issue devoted to CBT, you can learn more about —Frank G. Sterle, Jr., White Rock, BC what CBT is, who it works for and why. You will get the perspectives of individuals who’ve had experience with CBT. You will learn about some of the exciting new de- we want your feedback! velopments in this field. And finally, you will learn about some of the CBT resources that are available in BC. If you have a comment about something you’ve read in Visions that you’d like It’s my hope that, after reading this issue, you will to share, please email us at [email protected] with ‘Visions Letter’ share in my excitement about the potential benefits of in the subject line. Or fax us at 604-688-3236. Or mail your letter to the ad- CBT to help improve the lives of BC residents suffering dress on page 3. Letters should be no longer than 300 words and may be edited from mental illness. The desire to see that all British for length and/or clarity. Please include your name and city of residence. All Columbians are able to access this treatment is what letters are read. Your likelihood of being published will depend on the number keeps me going in my work. Perhaps it will also moti- of submissions we receive. vate you to talk to service providers and friends about the benefits ofCBT . Photography Disclaimer: Please note that photographs used in the print issue of Visions and online at HeretoHelp.bc.ca are stock photographs only for illustrative purposes. Unless clearly captioned with a descriptive sentence, they are not intended to depict the writer of an article or any other individual in the article. The only regular exception is the guest editor’s photo on page 4.

Footnotes Reminder: If you see a superscripted number in an article, that means there is a footnote attached to that point. Sometimes the footnote is more explanation. In most cases, this is a bibliographic reference. To see the complete footnotes for all the articles, see the online version of each article at www.heretohelp.bc.ca/publications/visions. If you don’t have access to the internet, please contact us for the footnotes by phone, fax or mail using the contact information on page 3.

Correction Notice

In the Cannabis edition of Visions, figure 2 in the article “Tobacco and Alcohol Use in Canada,” located on page 13, erroneously reported the costs of alcohol-related enforcement to Canadian society. The correct number is $3,072.2 million. Please see the online version for the corrected graph at heretohelp.bc.ca/publications/visions

Visions Journal | Vol. 6 No. 1 | 2009 5 background

When you have depression, anxiety or other disorders, you often have patterns of negative thinking. For example, you might automatically believe that you’re “never good enough” when one tiny part of a project doesn’t work out the way you planned. These thoughts can make you feel even more depressed or anxious. The negative thinking patterns listed below are common thinking patterns that can contribute to depression, anxiety and other troubling symptoms.

All-or-nothing thinking You see things in black-or-white categories. If a situation falls short of perfect you see it as a total failure. You see a single negative event, such as a romantic rejection or a career reversal, as a never-ending pattern Overgeneralization of defeat by using words such as “always” or “never” when you think about it. You pick out a single negative detail and dwell on it exclusively, so that your vision of all of reality becomes Mental filter darkened, like the drop of ink that discolours a beaker of water. You reject positive experiences by insisting that they “don’t count.” If you do a good job, you may tell Discounting the positive yourself that it wasn’t good enough or that anyone could have done as well. Discounting the positive takes the joy out of life and makes you feel inadequate and unrewarded. Jumping to conclusions You interpret things negatively when there are no facts to support your conclusion. Mind reading Without checking it out, you arbitrarily conclude that someone is reacting negatively to you. Fortune-telling You predict that things will turn out badly. You exaggerate the importance of your problems and shortcomings, or you minimize the importance of Magnification your desirable qualities. This is also called the “binocular trick.” Emotional reasoning You assume that your negative emotions necessarily reflect the way things really are. “Should” statements You tell yourself that things should be the way you hoped or expected them to be.

Mind Traps Labelling is an extreme form of all-or-nothing thinking. Instead of saying “I made a mistake,” you attach a Labelling negative label to yourself. Personalization and Personalization occurs when you hold yourself personally responsible for an event that isn’t entirely under blame your control.

Source: BC Partners for Mental Health & Addictions Information, Anxiety Disorders Toolkit

CBT in Practice Part science, part art Michelle Patterson, ognitive-behavioural ther- ative things that happen to them PhD, RPsych apy (CBT) combines basic and not notice the positive things. Ctheories about how people Or someone might set unrealistic Michelle is an Adjunct learn (behaviourism) with theo- standards for themselves, such as Professor and clinical ries about the way people think “making mistakes at work is un- psychologist working at about and interpret events in acceptable.” It’s also important the Centre for Applied their lives (cognition). CBT is now to identify unhelpful behaviours Research in Mental firmly established as the lead- that maintain symptoms, such as Health and Addiction ing psychological treatment for avoiding certain situations and (CARMHA) at Simon many mental health conditions. withdrawing from others. Fraser University Many research studies have dem- The client and therapist also onstrated its effectiveness.1 Re- look at how thoughts and behav- search shows that the skills peo- iours impact feelings. For example, ple learn through CBT last long if someone believes that nothing after the treatment ends.2 will work out for them in life, they may withdraw from In CBT, the therapist and the client work together others and avoid new opportunities. This, in turn, can to identify unhelpful patterns of thinking and behav- lead to feelings of increased sadness, emptiness and iour. For example, someone might only notice the neg- anxiety. This is sometimes called a “vicious circle” of

6 Visions Journal | Vol. 6 No. 1 | 2009 background

thoughts, feelings and behaviours. pist helped him iden- Carefully constructed exercises are used to help tify these beliefs and clients evaluate and change their thoughts and be- look at the evidence for Skilled practitioners are able to“ haviours. Some aspects of treatment focus more on and against them. He “ thoughts and some aspects focus more on behaviours. was able to learn that adapt CBT to a wide variety of If a client has difficulty identifying and challenging he viewed the world negative thoughts, the therapist might focus on ad- in black and white, and people and circumstances dressing behaviours such as avoidance, withdrawal or started challenging him- poor social skills. On the other hand, if such behaviours self to see the middle ground. John also learned to be are not as noticeable, the therapist may focus on chal- more assertive and to do more activities that made him lenging unrealistic thinking. feel good about himself.

Common CBT interventions include: Substance use disorders • setting realistic goals and learning how to solve prob- In the area of substance use, CBT was first used as lems (e.g., engaging in more social activities, learn- a method to prevent relapse when treating problem ing how to be assertive) drinking. It was later adapted to treat individuals • learning how to manage stress and anxiety (e.g., who are addicted to nicotine, cocaine, marijuana and learning relaxation techniques such as deep breath- other drugs. ing, coping self-talk such as “I’ve done this before, Cognitive-behavioural strategies for substance just take deep breaths” and distraction) use disorders are based on the theory that learning • identifying situations that are often avoided and processes, such as reinforcement and conditioning, gradually approaching feared situations play an important role in the development of addic- • identifying and engaging in enjoyable activities such tive behaviours. People learn to identify and change as hobbies, social activities and exercise problem behaviours by applying a range of different • identifying and challenging negative thoughts (e.g., skills that can be used to reduce or stop drug use. “Things never work out for me”) Specific skills include: • keeping track of feelings, thoughts and behaviours to • exploring the positive and negative consequences become aware of symptoms and to make it easier to of continued substance use change thoughts and behaviours • self-monitoring to recognize alcohol or drug crav- Source: BC Partners for Mental Health & Addictions Information, Anxiety Disorders Toolkit ings early on CBT is most widely applied to mood disorders (such • identifying high-risk situations for substance use as depression) and anxiety disorders. It is also used to • developing strategies for coping with and avoiding help people with substance use problems, personality high-risk situations and the desire to use disorders, eating disorders, sexual problems and psy- chosis. It is successfully delivered in individual, group The therapist and client work together to anticipate and couples formats. problems and develop effective coping strategies. Lynn has been struggling with problem drinking for Applying CBT for depression and several years. She knew there would be alcohol served problem substance use at the upcoming company party. She also knew her co- Depression workers sometimes drink too much and pressure her to CBT for depression usually starts with education about drink. Lynn and her therapist developed a plan before depression and helping the client understand their the party. Lynn decided to avoid punch and only drink symptoms as part of an illness that they can do some- what she could measure, have soft drinks until she got a thing about. feel for the party, have no more than one alcoholic drink, Treatment strategies include helping clients to stay no more than three hours and ask her boyfriend to establish structure around daily activities, to become pick her up. more aware of their mood and challenge negative thoughts, and to engage in pleasurable activities. Does CBT have limitations? The therapist and client work together to challenge CBT has been criticized as being overly rigid and negative attitudes the client holds about the self, the mechanistic, that is, focused mainly on an educational world and the future, which may contribute to feelings approach and setting goals. This may prevent an ex- of hopelessness. ploration of the big picture, which includes relation- John believed he was “no good” and a “failure” at ships, family of origin issues and emotions. work, in his romantic relationship and in his friend- Also, relatively little is known about the process ships. Over the years, he came to expect that bad things of matching treatments (including CBT) to individual For more information, see would happen and that things would always be difficult people. Skilled practitioners, though, are generally CBT—Core Information for him. This led him to give up on things quickly and able to adapt CBT to a wide variety of people and Document at carmha.ca believe that there was “no point in trying.” John’s thera- circumstances. >>

Visions Journal | Vol. 6 No. 1 | 2009 7 background

* See the article on CBT is not the best approach for all clients, how- the environment rather than a focus on thinking. SUCCESS’s adaptation ever. Individuals who have a more chronic or recur- The development of cultural adaptations to CBT is of CBT for BC’s Chinese ring illness may need repeated interventions. Or they still in the beginning stages. CBT is largely based on population on p. 23 may need a shift to approaches other than CBT to the values supported by the dominant culture. In North address early life experiences as well as personal- America, these values include assertiveness, personal ity, interpersonal and identity issues. And given that independence, verbal ability, logic and behaviour CBT is quite structured and tends to focus on thinking change. But specific manuals have been developed for rather than emotions, it may not be the best therapy adapting CBT to Chinese Americans and Haitian Amer- for people who have strong and immediate emotional ican adolescents.3-4 * reactions. More generally, when a client feels very emo- CBT should not be applied as a ‘cookie-cutter’ ap- tional, a focus on cognition and behaviour is less effec- proach. The therapist must carefully assess the client’s footnotes tive for change. motivations and how to best approach him or her. Oth- visit heretohelp bc.ca/ Although CBT has been used with children as erwise, the client may resist the treatment if they don’t publications/visions young as seven to nine years old, it’s most effective accept the model or don’t feel the therapist is listening for Michelle’s complete with children over 14. At this age, children have more to them. footnotes or contact us fully developed cognitive skills. Younger children, or Clearly, a skilled practitioner must apply CBT with- by phone, fax or e-mail teens and adults with cognitive disabilities, usually re- in a good working relationship with the client. This is (see page 3) spond best to behavioural strategies and structuring of the art, as opposed to the science, of therapy.

CBT: What Is It?

Nichole Fairbrother, ognitive-behavioural therapy lems. It is currently the psychological PhD, RPsych (CBT) is a kind of talk therapy treatment approach with the most that is used to treat a range scientific support. Nichole is a psychologist Cof different psychological problems and an Assistant Professor (see sidebar). CBT is collaborative with UBC’s Island Medical CBT is a merging of behaviour The client and the therapist work Program and Department therapy and cognitive therapy.1 Be- together to understand and resolve of Psychiatry. She has a haviour therapy first emerged in the the client’s difficulties. background in cognitive- 1950s and was based on the idea behavioural approaches that people can learn to change or CBT is educational to anxiety and depression. modify their behaviour.2-3 Cognitive All forms of CBT involve some edu- Her research is in the area therapy developed in the 1960s. cation about the nature of the cli- of reproductive mental The idea behind cognitive therapy ent’s difficulty and the elements of health, with a focus on was that how a person thinks about The ingredients in CBT will vary treatment. This education, often anxiety disorders their experience will have a signifi- depending on the problem being called psychoeducation, is provided cant impact on how they feel.4 Over treated, but there are a number of in the first one or two treatment time, these two approaches merged. common features. sessions. Sometimes clients are All forms of CBT are based on given handouts or other reading the idea that both our thoughts and CBT is evidence-based materials to provide them with in- behaviours play an important role There are many different kinds of formation about their problem and in our emotional experience. Some- treatments offered to help people. how CBT can help them. times our thoughts and behaviours Some treatments have been scientifi- can contribute to a negative emo- cally tested and others have not. Ev- CBT is short-term tional experience. A key assumption idence-based treatment means that a Cognitive-behavioural therapy will behind CBT is that the way we think particular treatment has been evalu- usually last anywhere from five to about events in our life has an im- ated in a scientifically sound way and 20 sessions. The number of ses- portant impact on how we experi- has been found to work well. CBT has sions depends on the nature and ence and respond to those events— been evaluated and found to work the severity of the problem being that is, how we feel and behave. well for many different kinds of prob- treated. Sometimes more sessions

8 Visions Journal | Vol. 6 No. 1 | 2009 background may be offered, especially if the cli- development, the client’s thoughts, ent needs help with more than one behaviours and feelings are a key CBT is effective for these problems: kind of problem. focus of therapy. Additional sessions, sometimes Thoughts: In CBT, the therapist TTanxiety disorders, TTmedical conditions, referred to as booster or refresher helps the client examine and evalu- such as social phobia, such as chronic pain sessions, may also be included as ate their thoughts in problematic obsessive-compulsive or cancer part of treatment. For example, one situations. This may involve teach- disorder, panic disorder, or two additional sessions may be ing the client to become aware TTsexual difficulties and post-traumatic stress scheduled to take place three and/ of their thoughts, monitor their disorder TTstress management or six months following the end of thoughts and come up with ways to TTdifficulty following the weekly therapy sessions. Boost- test the accuracy of their thoughts. TTeating disorders through with medical er or refresher sessions may also Testing beliefs may take place in TTdepression be scheduled by the client on an the therapy session (e.g., a client advice TTpsychosis as-needed basis. Booster sessions with panic disorder may engage in TTsleep disorders TTsubstance use problems can help to ensure that progress breathing exercises to test the be- TTimpulse control disor- in therapy is maintained. Also, lief that symptoms of panic lead TTpersonality disorders ders, such as patho- any new issues that arise following to fainting). Or a client may test TTanger management logical gambling treatment can be dealt with before beliefs as part of the their home- significant problems develop. work for the week (e.g., disclosing something personal to a friend to spend most of its time on beliefs CBT: becoming your test the belief that this will lead to and behaviours. own therapist rejection). One important goal in CBT is to Behaviours: Clients some- CBT is adaptable help the client become their own times develop certain patterns of CBT can be delivered in a variety therapist. This is done partly behaviour in an effort to experi- of formats and by a range of pro- through education and home- ence less distress. These patterns viders. For example, CBT can be work exercises. The therapist also may be helpful in the short-term, delivered to individuals or groups. teaches coping and other skills. but they can be unhelpful in the Often, CBT is provided by a trained The client learns new ways of do- long-term. For example, it is com- therapist, but it can also be facili- ing things and new ways of coping mon for people who feel anxious tated by a peer or a coach. Many that they can continue to use even in social situations to avoid these high-quality CBT self-help materi- after therapy has ended. situations. In the short-term, this als are also available and may be approach can help reduce anxiety. used on their own or as an adjunct CBT is structured But in the long-term, this way can to treatment. Therapy sessions in CBT are usually lead to social isolation and wors- Structured CBT treatments for focused on reducing the client’s ening anxiety. The therapist’s job many different types of problems current symptoms and improving is to help the client come up with have been developed. Some varia- their functioning. In order to stay new ways to handle social situa- tions of CBT have incorporated oth- focused, the therapist and the cli- tions that improve coping and re- er therapeutic approaches or tech- ent create a plan for the session to duce anxiety. niques. These include mindfulness make sure that what they cover will Feelings: Some of the tech- and acceptance and commitment be most beneficial to the client. niques used in CBT focus on directly therapy, which involves a collabo- changing how people feel. For ex- rative assessment of the client’s CBT and homework ample, relaxation techniques can values and goals. footnotes CBT aims to teach the client new significantly reduce feelings of ten- CBT is also very well suited visit heretohelp bc.ca/ ways of dealing with their emotions sion and stress. Most of the time, to being adapted to each client’s publications/visions and behaviours. The therapist will however, it is the focus on beliefs specific concerns. Structured pro- for Nichole’s complete ask the client to apply what they and behaviours that lead to im- tocols can be modified or blended footnotes or contact us learned in the therapy sessions to portant changes in feelings. Even to provide clients with treatment by phone, fax or e-mail their life outside of therapy. Typi- though the goal of therapy is to im- that is tailored to their specific (see page 3) cally, the client and the therapist prove how people feel, CBT tends to needs. will work together to set homework tasks at the end of the session for the week to come. TTAssociation for Behavioral and Cognitive Therapies related www.abct.org/dHome CBT focuses on thoughts, resources TTSociety of Clinical Psychology, American Psychological Association behaviours and feelings www.psychology.sunysb.edu/eklonsky-/division12 In addition to education and skill

Visions Journal | Vol. 6 No. 1 | 2009 9 experiences and perspectives

Conversations With Myself

Danielle Raymond f you had asked me when I was 16 if I thought Me, the marionette I’d be sharing my life with an eating disorder, I’d Life with an eating disorder (if you can call it “life”) is Danielle is a 24-year-old probably have said not likely. I may have added basically like a puppet show. You are the dancing, smil- psychology student at something about not having the strength or the will- ing marionette, and your disorder is the puppeteer. It Kwantlen Polytechnic Ipower to defy hunger. I had no idea that within a year calls the shots; it tells you when you’re going to eat University currently living I’d be popping diuretics like Tic Tacs and weighing and how much. It even writes the script, putting its in Maple Ridge. Always a my worth in pounds. Like so many other young wom- own values where yours used to be. All of a sudden, fighter, Danielle has been en—and men too—I wandered unknowingly into the you don’t care about your health, your friends or your battling an eating disorder arms of an eating disorder. We’ve been inseparable dreams. All you care about is being thin, and you don’t for almost eight years; she ever since. even really know how it happened or when or why. has been in treatment for I used to believe that if I tried hard enough, I could So there you go, smiling as your bony body bounc- the last four do anything. Not because I was smart or capable or es around onstage, and everyone claps at your slen- even creative, but because I was thin. It took me four derness and compliments you on how amazing you This article is dedicated years of trying to be perfect before I was finally exhaust- are. They don’t know that you go backstage and cry to Danielle’s little ed enough to admit myself into a treatment program. because you’re tired and hungry and afraid. sister Shannon And it has taken another almost four years of working with a multidisciplinary team of professionals—a psy- CBT vs. the ‘puppet master’ chologist, a doctor, a nutritionist and a psychiatrist—to If you’re in treatment for an eating disorder, chances unravel all the years of lies I’ve been selling myself. But are pretty high that your recovery will include some before I talk in depth about my experience, I think it’s form of cognitive-behavioural therapy (CBT). The out- important for you to understand why I couldn’t just eat patient treatment program I entered in the fall of 2005 a pizza and get over it. was no different.

10 Visions Journal | Vol. 6 No. 1 | 2009 experiences and perspectives

Essentially, CBT operates on the assumption that Challenging the mind traps; your thoughts and behaviours are linked. If you change tripping up the puppeteer one, the other follows suit. Clearly, my thinking had to change so my be- Now, my treatment team knew that asking me to just haviour could change. change my eating-disordered thinking would be about First I worked with self-monitoring work- Conversations With Myself as successful as asking someone with a brain tumour to sheets. When I noticed a sudden shift in my change their cancer cells back into healthy ones. This is mood, I tried to identify the automatic thoughts because the harmful pattern of thinking is so deeply in- by noting what the situation was, how I felt and grained and so sensitive to anything that might threaten what I was thinking. For instance: I could be at it that you almost have to trick yourself into changing it. the store buying food, when suddenly I feel a Whenever I went to eat something, the eating disorder al- need to go work out for two hours. I was able ways had something to say, dictating what I was allowed to discern that the thinking part had to do with to eat: “Are you stupid? You can’t eat that!” seeing a magazine cover glaring something From the beginning, my doctor and psychiatrist about cellulite and weight. My therapist and I prescribed medication to help reduce the depression did a lot of talking about what was on my sheet. and obsessive thinking patterns that kept me locked Then my therapist helped me learn to into the disorder. At the same time, my therapist (psy- identify what are called mind traps.* I was a chologist) helped me challenge my thoughts. Luckily big “black and white” thinker: “If I’m not size zero, I clicked with her, so I hung in there. But my attitude then I’m obese.” was: “We can talk about change, but I’m not ready to I was also very good at “catastrophic” thinking: “If * See chart of negative make changes.” After all, my original motivation for I don’t get an ‘A+’, I might as well have an ‘F’ because thinking patterns going into treatment was to get information that I I’ll never get into grad school and I’ll be stuck working on p.6 could use to further manipulate my diet and sustain at some minimum wage job forever.” my eating disorder. My therapist would guide me to play out the ‘logic’ The treatment team’s plan was to have me make of my thinking. For instance, if I told myself that I de- small, manageable changes in my behaviour. Sounds served to die because I’d gained five pounds, she might simple, right? Well, it was neither small nor manage- ask me to take a third-person point of view. “What if able. They asked me to do things that horrified me, your friend gained five pounds? Would you tell her she like eating regularly whether I was hungry or not. deserved to die?” And, of course, I wouldn’t; I’d never They explained that because I’d been ignoring my think that way about others. body’s hunger signals for so long, the signals weren’t My therapist sometimes had me play devil’s advo- working properly any more. To me, however, eating cate and talk about why I felt that I deserved to die for more often sounded like a quick and dirty recipe for gaining five pounds. Then she’d point out that, accord- weight gain. ing to my own logic, everyone who gained five pounds No matter what the treatment team said and how deserved to die. “No,” I would say, “it’s only me that much sense it made, I told myself I could never do any deserves to die.” But when she asked me to explain, I of it. Being thin and perfect was more important. couldn’t because I knew it didn’t make any sense. But they pushed on. My nutritionist said that I At first, this CBT process felt like barrelling through was falling asleep in class because I was hungry and untamed woods: you don’t get anywhere. I had to keep needed to eat something. I pushed back. My eating going over and over the same path to forge a trail and disorder said that I was just being lazy and that my shift my thinking. It’s taken years, but slowly I’ve been nutritionist was trying to make me fat. My doctor told able to reconnect with myself and push the eating dis- me that I was getting dizzy at the gym because I wasn’t order aside. eating enough to sustain physical activity. My eating disorder told me that I was just being a wimp and that Many strings severed; more to go my doctor didn’t know anything about fitness. I firmly Every single day I work hard at recovery. I’m still in convinced myself that if I listened to them, I’d lose all treatment—I see the therapist every two or three control, gain a million pounds and become a lazy, pa- weeks now, instead of weekly. I’m learning to accept thetic and horrible person. my vivaciousness, my sensitivity and my own human- After about a year of this kind of internal arguing ness. I don’t have to be size zero, it’s okay if I don’t and resistance, I was able to admit that I had a prob- get an A+ in every course I take in school and I’m not lem. I was tired—attending school full-time, holding going to die if I have a chocolate bar. My ultimate goal down three different jobs and working out in the gym is not to have to rationalize every perceived “failure.” seven days a week. The busier I was, the less I had When things get tough, however, the marionette time to eat; but I had no energy and was falling apart. version of myself—that negative, eating-disordered Even worse, despite all of my efforts to avoid it, I’d voice—still comes around. Most of the puppet strings been gaining weight—I felt that my body had finally have been severed, but not all. Even though I’m not betrayed me. cured, I am definitely getting better.

Visions Journal | Vol. 6 No. 1 | 2009 11 experiences and perspectives

From Pain to PTSD Running the gamut of CBT

Lynda Marie Neilson had a serious motor vehi- me with PTSD; this was cle accident nine years ago about one and a half years Lynda worked in hotel Iwhile working for a very post-accident. Not only was management and the high-paced software company. I anxious about driving my software industry before I was in Ottawa—far from my car, but by now I was having she had a workplace home in Vancouver—driving insomnia and nightmares— accident. She’s been to a client’s suburban location. images of my accident con- diagnosed with post- Another driver wasn’t paying stantly replayed in my mind. traumatic stress disorder, attention when changing lanes I also had intrusive thoughts major depression, a spinal and rear-ended me at high during the day, where I felt like injury and myofacial pain. speed. I ended I was back there, Lynda studies part-time up in a multi-car reliving the acci- at BCIT and UBC. She accident involv- I was having nightmares— dent. I felt angry aims to earn a BAdmin ing nine vehi- images of my accident constantly at the world and before she’s 50 cles. Numerous had a low toler- ambulances and replayed in my mind ance for other fire trucks were people (whereas called. I had to wait on the side of For homework, I had to log my before I’d been a super people per- the road in the minus 40 degree experience of pain so we could see son). Another thing that had pro- weather, hearing sirens wail and what the flare-up patterns might be. gressively gotten worse was that my wail as they tried to get through the The psychologist also trained me to arms and hands would involuntarily backed-up traffic. do imaging; that is, make mental wave and clap whenever I saw fire I continued to work after the images to call up when my pain trucks, heard sirens or was put in a accident, even though I had shoot- is severe. I bring up an image of a position of increasing stress. I had to ing pain and numbness in my right beach I visit in Maui; this mental stop driving altogether. forearm and hand as well as poor ‘retreat’ helps ease the pain. The The CBT for PTSD was really concentration. The pain increas- psychologist also taught me breath- intense. It involved exercises like ingly affected my work output, so ing exercises to do when the pain visualizing the accident, writing the Workers’ Compensation Board is strong. So, for instance, in a down the details of the accident, (WCB) [now called WorkSafeBC] meeting at work, I could deal with tape recording myself telling the sent me to a psychologist for pain a surge in the intensity of my con- story of my accident and watching management techniques. That was stant pain by changing my breath- tapes of other accidents—over and the start of my cognitive-behaviour- ing pattern. over. This is called exposure thera- al therapy (CBT) treatments. In talking about my pain, it be- py. These exercises were done both came apparent to the psychologist within the safe environment of the From CBT for pain... that something more than physical psychologist’s office and at home CBT deals with changing a person’s pain was going on. I told him I was afterwards. thought patterns so they have a quite uncomfortable driving my car. These tasks are not easy to do; better and more positive under- I stayed off highways and took side they bring up bad memories of the standing of things that have hap- streets to avoid busy thoroughfares, accident. Working with the brain to pened to them. In these sessions, as these reminded me of my acci- change the memory patterns is a the psychologist and I looked at dent. He mentioned this in his case long, exhausting process. However, behaviour, physical symptoms and report to WCB, and I was moved to with repeated exposure to the sto- thoughts. We talked about how another psychologist who special- ries of the accident, the incidence there is a psychological aspect to izes in CBT for post-traumatic stress of these images and memories has pain and that we can change our disorder (PTSD). very slowly decreased in frequency. experience of the pain by chang- We also incorporated the imag- ing our thoughts and behaviours in to CBT for PTSD... ing and breathing I had previously response to the pain. The new psychologist diagnosed learned. Plus, the psychologist

12 Visions Journal | Vol. 6 No. 1 | 2009 experiences and perspectives grounded me, bringing me back to in the group. I only found comfort reasonable range the present when I’d get lost in the with my psychologist, because it’s was from 30 to 60. memories of my accident (i.e., was clear that the PTSD drives my depres- If we thought our- triggered). I then learned to ground sion. He continued to work with me selves higher, then myself, by rubbing my legs or the on exposure analysis. As homework, we would draw on handles of a chair, or running my I practised increasing my tolerance our CBT skills to hands over the keys of my laptop. for walking outside where I was near bring our anxiety (This was actually a first taste of cars. He also worked with me on the into a more accept- mindfulness-based CBT). depression in sessions by having me able range. write a task list for the coming week, to CBT for depression... then having me revise it to be more to synthesis! In spite of two years of therapy, my reasonable. Finally, in the VGH PTSD had become chronic (it lasted PTSD outpatient more than six months). And after to mindful CBT for anxiety... group, all the being a highly regarded employee Once my depression was under therapy I’d done for nine years, I suddenly lost my control, a neuropsychiatrist (UBC over the previous job in March 2003. Major depres- Hospital had referred me to him for seven years came together. I got a sion ensued. I ended up in Vancou- my arm-waving movement disor- grasp on PTSD and began to work ver General Hospital (VGH) before der) referred me to VGH’s PTSD pro- with it to enable me to get going finally being moved to theUBC Hos- gram. There was a year-and-a-half with my life. pital mood disorders ward. wait for the program, so the intake There were three parts to this While in the hospital, I was con- psychologist referred me to the VGH program. The first part consisted sidered too fragile for the rigours of outpatient group for generalized of one-on-one sessions with a psy- CBT. I did a little swimming and anxiety disorder (GAD). chiatric nurse to ensure I had the walking. This may have been help- The GAD group was also in a necessary skills for the next phase. ful for the depression, but my hos- CBT format; however, they were us- The anxiety scale, for example, was pital stay was not good for the PTSD. ing a technique called mindfulness- one of the tools that was needed, I wasn’t allowed to stay in the hall- based cognitive-behavioural ther- as well as imaging, breathing and way at night when I retreated there apy (M-CBT). Mindfulness is about basic information about PTSD. Be- from nightmares. And another pa- being in the present moment, the cause of my years of CBT therapy, tient in the semi-private room kept here-and-now. Through mindful- I only needed a few sessions to be startling me at night, which made ness, I was able to start changing ready for the next phase. my insomnia worse. my negative self-talk by observing The second part of the pro- But we did have group therapy my behaviour and thoughts, and gram was a 28-week group ses- meetings, which was great for me. then coaxing the negative behav- sion led by the nurse and a psy- I had lost contact with people and iours and thoughts to become posi- chiatrist. The group was in M-CBT felt very alone, so it was wonderful tive ones. This also helped me deal format like the anxiety group and to have people to talk with. I was with my anger. included relaxation at the end of able to realize that I wasn’t alone in For example, at home I some- each session. Stress reduction my depression. times find myself getting angry at is very important in PTSD. They UBC Hospital staff recommend- noise from outside—such as roof- compared it to a car engine, which ed that I take Changeways, an outpa- ers working—and have an impulse can go from zero to 4,500 revs a tient program for depression offered to storm out and express that an- minute. A person without PTSD by the hospital at that time. So, after ger. With mindfulness, I will take generally idles at about 1,500 I was discharged, I took the eight- a moment, bring myself into the rpm, but someone with PTSD idles week, once-a-week program. present by feeling where I’m sit- at 2,500. When a person with We did CBT in a group environ- ting and then maybe draw on im- PTSD is stressed, they have less ment. I learned how to organize my aging to feel myself in Maui so that room to deal with the stress be- time to reduce my stress. I was ac- I relax. fore reaching 4,500 rpm. customed to the high-paced, multi- I also started knitting, which I The really powerful aspect of tasking environment of my former learned as a child. This is a form the group session was that, starting workplace, but learned to look at of relaxation I can do anywhere— about week 12, each group mem- one task at a time and just one day on the bus, in a car or waiting for ber had to explain their traumatic at a time. appointments. experience. The facilitators asked I was still alone in my PTSD, how- Another very important tool us questions so that we’d be trig- ever. No one else in the group had learned in this group was an anxi- gered and relive the traumatic this diagnosis and I was constantly ety scale from zero to 100, used event—I found out that red car tail being triggered by comments made to self-assess our anxiety levels. A Continued on page 14 >>

Visions Journal | Vol. 6 No. 1 | 2009 13 experiences and perspectives

When Life’s Demands Take Their Toll Changeways for depression

Pat Merrett y husband Joe couldn’t figure out why this was mother was diagnosed with a serious illness and then, happening. He was 58 years old and was sit- in 2000, just as she completed her treatment, I was Pat is Media Director M ting in the backyard crying. And it wasn’t the diagnosed with cancer. As an only child and a spouse, for the Mood Disorders first time. it was natural that he be- Association of BC (MDA). In July 2009—sev- came the primary care- MDA provides support for en years later—Joe at- giver to both. those living with a mental tended his first session Friends and family illness and education of the Changeways pro- were very helpful and as- to increase awareness gram. This is a weekly sisted with the caregiving and understanding of group program based as much as they could, but mental health issues; on cognitive-behavioural nobody recognized that Joe visit www.mdabc.net therapy (CBT). It teaches needed help too. The stress problem-solving and life- and the worry associated style management skills with caring for the two peo- as related to negative ple closest to him were tak- thoughts, social interac- ing their toll. tion, stressors and re- In the year following lapse prevention. my recovery, I came to rec- In looking back, Joe ognize that something was has come to realize that wrong. For the life of me, I he has lived with depression for most of his life. couldn’t understand why Joe, who’d been so support- ive through my illness, now seemed to hate me and The erosion of good cheer... fought with me almost every day. Joe’s depression never became apparent until after I feared we were headed for separation, if not di- he’d gone through two very stressful years. In 1999, his vorce. To the rest of the world, he was the same Joe >>

From Pain to PTSD | continued from previous page

lights were a major trigger for me. always shared and explored our apy process, I never thought CBT When I began to dissociate (not to experiences of working with the would work for me. Back when be present mentally), the psychia- M-CBT tools in our day-to-day lives. I was recording stories of my ac- trist coached me to apply the M-CBT cident, I felt I was getting worse techniques. And now... rather than better. But now I feel Doing this process actually I’m now back to one-on-one ther- that it’s been a success. When trig- caused me to be hospitalized at apy, seeing a new psychologist gered, I can acknowledge the PTSD VGH for a couple of weeks during for return-to-work issues. We do images, rather than pushing them the group due to depression from less cognitive-behavioural work— away. This has lessened my arm the PTSD. However, experiencing though I do monitor and log my movements, as I’m managing my the trauma in the group setting, pain, anxiety and mood—and do stress better. I can walk more of- the recovery, the sharing, using more talk about socialization. But ten on a busy street and am more the anxiety scale—it all did me the theory behind CBT and M-CBT at ease in cars, though I’m still wonders. is really strong. You have to take not driving. I volunteer, go to ap- The third part of the program time daily to practise it, but for pointments, run errands and work was 40 weeks of a support group those who do, it works to reduce at living a stress-free life. My next led by the nurse. Sometimes we fo- the stress of living with PTSD. steps: getting back to work and cused on particular topics. But we While going through the ther- getting my degree!

14 Visions Journal | Vol. 6 No. 1 | 2009 experiences and perspectives they’d always known, though maybe a bit grumpy it, with a waiting time of on occasion. about two months. Sure how to access mental As good luck would have it, I began volunteering enough, two months with the Mood Disorders Association of BC and hap- later Share contacted health programs pened to read an information sheet that listed the him and, at the time of i symptoms of depression. It was Joe! writing this, he had at- You can ask your family doctor, psychiatrist, When our next argument took place, I thrust the tended four of the eight mental health team, the outpatient psychiatry sheet at him and told him to read it. When we dis- sessions. program at your local hospital or your therapist cussed it later, he admitted that almost all the symp- Initially Joe had sec- about mental health programs. toms applied to him—lack of energy, withdrawal ond thoughts about at- from friends, aches and pains, pessimism, irrita- tending the program; For tips on talking to your doctor about mental bility and anger, and problems sleeping. Since I’d he’d never belonged health problems, see the Getting Help for Mental been expected to go the doctor for treatment when I to a support group and Disorders fact sheet at www.heretohelp.bc.ca/ was diagnosed with cancer, I expected Joe to do the wasn’t sure how it would publications/factsheets/help-md. same. He agreed. work. And, because it’s The doctor was surprised to find that Joe had a quite a diverse group Here are some resources to help you find mental illness and said that if Joe hadn’t come in of people, he wondered programs or courses in your area: with that list he would never have diagnosed him how much would actu- TTHere to Help with depression. Joe had never told the doctor that ally apply to him. www.heretohelp.bc.ca he wasn’t feeling well. And, because Joe always But Joe is discover- Ask for local resources, or share CBT programs appeared so cheerful, the doctor never asked; Joe ing that he’s benefiting or information, on the message board masked his depression well. But the doctor pre- from the program. His TTHealthLink BC scribed an antidepressant. classmates are both 811 or visit www.healthlinkbc.ca Once he was on a treatment plan with medication male and female, with Provides information on services in BC that worked for him, Joe realized how good he could a range of ages. Like TTCanadian Mental Health Association feel—not super happy, but okay. He described it as him, they’re willing www.cmha.bc.ca being “level” or “in the middle” and said he couldn’t to discuss their reac- Provides information, resources and links to remember ever feeling like that before. With some ad- tions to those everyday CMHA branch offices across the province justments over the years, the medication has helped events that sometimes Joe live with his illness. trigger and aggravate TTKelty Resource Centre their depression and 1-800-665-1822 or 604-875-2084 (Vancouver) CBT skills are helping anxiety. For Joe, it’s Provides mental health and substance use Joe is now 65 years old and realizes that he’ll have to concerns such as unfa- information, referrals and support for deal with his depression for the remainder of his life. miliar social situations, children, youth and their families. Although he continues to take medication, he’s ac- his aging mother, the TTMood Disorders Association of BC cepted that perhaps he needs further help dealing with economy and future fi- 604-873-0103 or visit www.mdabc.net day-to-day situations that can send him into a depres- nancial security, his and Offers support groups throughout the sive state. the family’s health and province, including family, young adult and I encouraged him to go to Changeways. Many MDA severe illnesses of life- faith-based groups. There are also free members have taken the program and found it ben- long friends. Discussing education evenings by experts in the field. efited them. I had also heard of encouraging research possible reasons for his into CBT as a treatment for depression. reactions and learning After discussing it with his doctor, who also en- skills to minimize the couraged him to attend the program, Joe contacted negative effects of these reactions is proving to be a the Share Community and Family Services Society of- positive influence in Joe’s relationships with family fice in Port Moody, where a Changeways program was and friends. being offered. He was pleased that a program was be- He feels comfortable with the instructors because ing offered in our community. Joe inquired about the they listen thoughtfully and encourage, but do not re- availability, cost, waiting time and referral process, quire, participation. Though he’s still a bit uncertain and was surprised to find that the cost was covered about the format, he’s optimistic that the program, by Fraser Health. along with his medication, will help him to better live All he had to do was contact the Tri-Cities Men- with his mental illness. tal Health Team for a telephone interview. They asked him some basic identification information and who his doctor was. After the mental health team had checked with the family doctor, Joe was placed on the list for the next class. The group is run as often as there’s demand for

Visions Journal | Vol. 6 No. 1 | 2009 15 alternatives and approaches

The LEAF Program Peer-led group CBT

Shelly Jones n 2004, I was diagnosed with how to manage anxious feelings in ing strategies. And, it’s been my ex- generalized anxiety disorder the body. We were also instructed perience that group members tend Shelly is the President I(GAD) at the Anxiety Disor- in the use of a 10-week group pro- to look to one particular co-leader of the board of ders Clinic at UBC Hospital. I was gram manual. for support, perhaps feeling that directors of AnxietyBC. fortunate to be referred to a group We continue to receive weekly person is more in tune with their The organization is for GAD based on cognitive-behav- phone supervision from one of the situation. committed to increasing ioural therapy (CBT), led At the first session, awareness, promoting by three psychology resi- we share our experienc- education and improving dents specializing in CBT es with anxiety. As lead- access to programs that and anxiety. By the end ers, we are open about work for those suffering of the 14-week group pro- our own struggles and from anxiety disorders. gram, I felt like I’d been the successful treat- She has co-led LEAF given my life back. So I ment we’ve received. groups since 2005 asked if there were any When the group mem- volunteer opportunities bers hear the personal to help others struggling stories of the leaders with anxiety. AnxietyBC and how they’ve been was seeking volunteers able to overcome their for their LEAF program. fears with the help of The LEAF (Living Ef- CBT, they realize that fectively with Anxiety it’s possible to manage and Fear) program is for people clinicians/CBT specialists to trouble- anxiety, whatever its form. And, with mild to moderate panic disor- shoot any difficulties that may have as a result of our openness, group der. It was developed by AnxietyBC arisen in the group and to review members are more willing to share in 2002. It has since offered CBT- material for the upcoming session. their own experiences based, peer-led panic management For many, this is the first time groups in various locations through- How the group works they have openly talked about their out BC, including Kamloops, Kelow- Throughout the 10-session program, struggles. A group participant once na, Delta, Surrey and the Tri-Cities LEAF leaders teach and model evi- said to me, “When I speak with my (Coquitlam, Port Coquitlam and dence-based CBT strategies that will doctor, I know that he doesn’t have Port Moody). help group members manage their any idea what I’m talking about The LEAF group leaders are panic symptoms. and cannot possibly understand former anxiety sufferers who re- Twelve people is the optimal what I go through. But you do be- ceived cognitive-behavioural ther- group size. The groups are co-ed cause you’ve been there.” apy to manage their anxiety. So (although women predominate, as In the first session, we also leaders have first-hand knowledge anxiety tends to be more prevalent provide factual information about of successfully overcoming prob- in women than in men) and mul- panic attacks and panic disorder so lem anxiety using CBT techniques. ticultural. Young adults as well as group members can begin thinking Although I was diagnosed with GAD seniors have been represented. rationally, rather than emotionally, rather than panic disorder, the feel- There are always two group about what is happening to them ings of being overwhelmed by anx- leaders, both with the peer-leader when they have a panic attack. And iety, the muscle tension and stom- training, to share the tasks of pre- they are given a book about anxiety ach distress, worry and avoidance senting the material and demon- and panic disorder (10 Simple Solu- are common to both disorders. strating techniques. Each leader tions to Panic: How to Overcome Pan- The peer-leader training in- has their own unique anxiety ex- ic Attacks, Calm Physical Symptoms, volved an intensive two-day work- periences and will answer group and Reclaim Your Life by Martin M. shop. We learned how to conduct questions a little differently. This Anthony and Randi E. McCabe). exposure to feared situations, how provides participants with a broad- In week two we introduce re- to challenge anxious thoughts and er perspective on anxiety and cop- laxed breathing, and deep muscle

16 Visions Journal | Vol. 6 No. 1 | 2009 alternatives and approaches relaxation is introduced in week make ourselves dizzy by spin- four. These are useful skills for re- ning around, all the while ex- ducing overall anxiety. The group plaining what we’re feeling. leaders always demonstrate each We acknowledge that, while behaviour or technique prior to we’ve made ourselves uncom- asking the members to join in. fortable, what we’ve done is At the end of each group ses- not dangerous. In fact, we’re sion, the participants are given able to report that, not long “homework.” Homework gives par- after we’ve stopped, all sensa- ticipants the opportunity to master tions are gone. the skills they’ve learned during ses- This exercise can sions. They may be asked to read a be scary for many chapter or two in the book they re- group members, but ceived. They work through exercises when we ask them We ask group members to start thinking in a workbook to help them identify to bring on a particular sensa- about a life outside of panic, where ‘harm and overcome their personal fears. tion along with us, very few They learn to challenge some of refuse to do so. This is an im- avoidance’ is not the primary focus the common types of thoughts portant step for participants that arise during a panic episode in understanding, experientially, in people who complete the pro- and identify a calming thought that that the physical sensations they gram.1 Group participants fill out can be substituted in place of the fear aren’t dangerous. pre-treatment and post-treatment panic thoughts. They set goals they The remainder of the program questionnaires. The majority, if can work towards as the program focuses on gradual and repeated ex- not all the participants, have re- progresses. And they are asked to posure to feared situations, moving ported that the LEAF program continue with the relaxed breath- from the easiest towards the most helped them manage their panic ing and deep muscle relaxation on a feared. These are situations that and anxiety symptoms more ef- daily basis to “dial down” their gen- have mostly been avoided in the fectively. Most participants would eral level of anxiety. past, such as driving over bridges also recommend the program to Homework is always reviewed or taking public transit. We also ask others suffering from panic disor- at the following group and par- the group members to start think- der. ticipants are encouraged to share. ing about a life outside of panic, Unfortunately, this program There is always reluctance at first. where “harm avoidance” is not the has not been offered on a regular But as group members hear the primary focus. basis due to inconsistent fund- experiences of others and discover At the final group, we usu- ing from the local health authori- that they’re not unlike their own, ally end with a celebration. People ties. This is a situation I hope will some of the stigma is removed bring food to share and many times change. Peer-led groups are a very and they begin to participate. Of- members share upcoming events cost-effective way to help people tentimes, group members begin they have planned that wouldn’t before their problems become to brainstorm coping strategies for have been considered before taking more severe and they begin to ac- each other. This is very exciting be- part in the group, like taking a trip cess the health care system more cause they are beginning to move that involves flying somewhere. We frequently. from purely emotional thinking encourage participants not to let I’ve met many brave and won- to more analytical and cognitive their panic management tools get derful people who’ve been strug- footnotes thought processes. rusty. We ask them to think about gling for years and who finally see visit heretohelp bc.ca/ The most challenging session what they knew about anxiety at a light at the end of the tunnel. publications/visions occurs about halfway through the the beginning of the group and They are my inspiration to continue for Shelly’s complete program, when participants are what they now know at the end. I helping those who haven’t yet ben- footnotes or contact us asked to bring on the bodily sensa- also like to let them know that, in efited from any form of treatment by phone, fax or e-mail tions they fear. People with panic practising anxiety management and struggle to cope day by day. (see page 3) disorder may be afraid of sensations techniques with them, I’m helping like a racing heart, light-headedness, myself as well. In many ways, lead- dizziness and shortness of breath. ing a group is my therapy. First, group leaders demon- related resource strate bringing on these uncom- LEAF has a positive impact fortable physical sensations, in a Data collected over the years shows calm and matter-of-fact manner. that the LEAF program success- TTAnxietyBC For example, we might cause light- fully reduces symptoms of panic, www.anxietybc.com headedness by hyperventilating or anxiety and associated depression

Visions Journal | Vol. 6 No. 1 | 2009 17 alternatives and approaches

The Cognitive-Behavioural Approach to Treating Individuals with Eating Disorders

Ron Manley, PhD, RPsych etty’s* challenge Let’s look at the example of Betty getting on a bus. Betty had been diagnosed with bulimia nervosa Due to her marked preoccupation with her weight and Ron is a psychologist with B(BN). She was depressed and terrified about gain- shape, it’s not unusual that she’d assume others would the Provincial Specialized ing weight. One day she didn’t attend her scheduled ther- be similarly preoccupied with her weight. She might Eating Disorders apy session. get on the bus and notice another pas- Program for Children When I phoned to follow up, senger looking at her. Her initial ten- and Adolescents at BC Betty explained that she couldn’t dency might be to conclude: “That per- Children’s Hospital. He come because she knew other peo- son agrees that I’m fat and shouldn’t has worked in the field of ple on the bus would be thinking be out in public.” This thought would eating disorders for over about how “fat” she was. reinforce her belief that she’s “fat” and 25 years We took this issue up in our needs to lose weight, and would lead next session, when Betty was able her to feel very badly about herself. Ron thanks his colleague to get a ride in with her mother. However, in the same situation, Dr. Karina O’Brien for her Over the course of the session, a person could alternatively conclude helpful comments on an we discussed body image distor- that the passenger looking at them is earlier draft of this article tion. This is when a person actu- admiring their clothing or appearance. ally sees and/or feels their body If Betty thought this way, she wouldn’t * pseudonym to be larger than it really is. That feel badly at all. is, their perception of their size is So we have two identical situations distorted. that resulted in each person feeling I was able to gently challenge very differently later on. Each of these how realistic her thoughts about people has attempted to understand, taking the bus were. At the same explain and interpret why the person time, it was essential for me to accept that her beliefs on the bus was looking at them. But they each thought and concerns were very real for her. very differently about the situation. I asked Betty how likely it was that anyone would These types of thoughts are called “automatic really notice her in a negative sense. She was able to thoughts.” They are automatic because they happen see just how improbable it was that anyone on the very quickly. Sometimes they are helpful and allow us bus would think badly about her or her appearance. to evaluate a situation quickly, but other times they’re Betty was also able to appreciate that people riding a very negative and unrealistic. bus were in general more preoccupied with their own If the thoughts tend to be very self-critical, it’s not thoughts and tasks for the day than concerned about hard to understand how someone could feel depressed her appearance. as a result of the thoughts. If the thoughts tend to be While this may sound like a common sense ap- threatening and involve the future, we can understand proach to take in this situation, it’s an example of how someone might feel very anxious. With an eating cognitive-behavioural therapy, or CBT. The “cognitive” disorder, the thoughts often similarly involve depres- refers to thoughts. The “behavioural” refers to the per- sion and anxiety, but include thoughts related to the son actually doing real-world things that demonstrate person’s feelings about their shape and weight. that their thoughts are unhealthy and, ultimately, don’t reflect reality. What is the evidence for CBT in the treatment of eating disorders? The CBT model CBT has been researched more than any other psycho- The CBT view is that people’s emotional states are a therapy in the treatment of eating disorders. This is par- result of how they think about or interpret different ticularly true in the treatment of bulimia nervosa (BN).1 situations and not necessarily an inevitable result of As a result, we can say with certainty that CBT is the particular situation. the treatment of choice for adults with BN.2 CBT’s effi-

18 Visions Journal | Vol. 6 No. 1 | 2009 alternatives and approaches cacy in the treatment of people with anorexia nervosa challenging automatic negative thoughts. For example, is less clear. It’s also unclear whether CBT has the same we help the patient ask, “What is the evidence?” for success with youth suffering from BN, since there’s a negative thoughts related to body image distortion. lack of research and scientific data in this area. In my This can empower the patient to work at diminishing experience, however, there’s little reason to doubt that the power these thoughts have. CBT is equally effective if modified to fit this younger These thoughts don’t simply disappear upon age group. first challenge; they must be challenged repeat- At the same time, it’s important to remember that edly. Patients also begin to become aware of recur- CBT is not a cure-all for every patient with BN, and fur- ring themes related to their thoughts. Feeling they ther research to increase its effectiveness as a treat- don’t deserve to receive help is an example of such ment is needed. a theme.4 On a level deeper than automatic thoughts lie Traditional CBT for bulimia in practise schemas, which are more enduring beliefs. These help Traditional CBT has long been applied to bulimia ner- determine the person’s experience of being-in-the- vosa and is often referred to as CBT-BN. The initial goals world. An example would be the belief that, “No one are to interrupt the symptoms, such as bingeing and would like me if they really got to know me.”5 And purging.3 Later, the main task is to help the patient again, the patient can question what evidence there question and challenge the thoughts and beliefs that is for their beliefs. maintain the eating disorder. The best way to disprove the apparent truth of There are usually a limited number of CBT sessions negative thoughts and beliefs is through real-world ex- (19 over 18 weeks),3 and homework is typically as- periments. The patient is asked to collect “data” both signed at the end of each session. The homework is in support of and against the belief. For example, Betty usually a combination of self-monitoring and behav- will be encouraged to take graduated risks with nor- ioural “experiments” to be carried out between thera- malizing her eating behaviour, to test out the eating- py sessions. disordered thought that she will gain weight in an out- Self-monitoring is where the patient is asked to of-control fashion. keep a log or journal of situations, thoughts and result- Sometimes I use a “courtroom and lawyer” anal- ing feelings. With Betty, I designed a form she could ogy. Negative automatic thoughts tend to have a use to record her negative thoughts and feelings, how persecutory quality. I make it clear that the eating these related to particular situations and whether she disorder is like a prosecutor in court. Patients are restricted, binged and/or purged as a result. aware that cases are thrown out of court when the This journalling is intended to increase awareness apparent “evidence” the prosecutor brings forward that eating-disordered behaviours take place in a con- is seen as insubstantial. CBT helps patients learn text of thinking and feeling. The patient becomes much to question the “evidence” that the eating disorder more aware of their thinking, which helps to take the brings forward. eating-disordered behaviours off “automatic pilot.” Over time, Betty will learn to challenge her eating- Self-monitoring must be introduced gradually. disordered thoughts and beliefs on her own. And she’ll Just learning to distinguish between a “thought” and be able to take increasing charge of her mood. This will a “feeling” can be very difficult. For some people with help to restore a sense of control, a sense of choice and eating disorders, learning to tell the difference between her self-esteem. certain feelings—distinguishing between hurt and an- ger, for instance—is an important and crucial step. CBT-E and other CBT offshoots show promise One may need to begin by learning names for various Enhanced CBT, or CBT-E, is a relatively new form of this feeling states. The person can then develop, as would therapy. A five-year study suggests that CBT-E is “more an artist, a more varied palette for expressing and de- potent” than CBT-BN.6 scribing their feelings. Disappointment, frustration, In CBT-E, the traditional CBT model of bulimia ner- boredom, loneliness and more may be identified. vosa treatment has been broadened to treat all the ** See chart of negative Another goal is to help patients learn to classify eating disorders. It has added modules that target per- thinking patterns on p. 6 their cognitive distortions into different categories. fectionism, self-esteem issues and relationship chal- These categories include “all-or-nothing” thinking, lenges. There is also a version for patients less than footnotes “mind reading,” “emotional reasoning,” “personali- 18 years of age. visit heretohelp bc.ca/ zation,” and so on.** An example of all-or-nothing There’s further good news. There are many other publications/visions thinking (also known as “black and white” thinking) offshoots of classic CBT that show promise in helping for Ron’s complete is the patient seeing him or herself as only very thin patients with eating disorders. These include dialecti- footnotes or contact us or fat—there are no in-betweens. Being able to classify cal behaviour therapy,7 acceptance and commitment by phone, fax or e-mail thought distortions helps patients appreciate that their therapy8 and those approaches derived from the (see page 3) thoughts are unrealistic. emerging literature on mindfulness.8-9 It’s very helpful for a patient to learn strategies for

Visions Journal | Vol. 6 No. 1 | 2009 19 alternatives and approaches

Metacognitive Training Influencing schizophrenia treatment worldwide Todd S. Woodward, PhD hat is metacognition? “Meta” means above and Jumping to Conclusions—a MCT Exercise Todd is an Assistant “cognition” refers to think- W This module shows 1 Does this look like a Professor in Psychiatry ing or perceiving. Thus, metacognition how what appears to sled or a bowl to you? Is at UBC and a research is being aware of one’s thoughts—or, be true at first often this possible, or prob- scientist at the BC Mental thinking about one’s thinking. turns out to be inac- able? Do you need more Health and Addiction curate once more information, or do you Research Institute. He About metacognitive training have enough to decide? information is gath- is the co-creator of Metacognitive training (MCT) is a ered. We will look metacognitive training program developed directly from at parts of a picture 2 Sled? Rocking (MCT) with primary current cognitive neuropsychiatry and see whether the chair? Elephant’s head? developer Steffen Moritz research findings on schizophrenia amount of information Do you need more of the University Medical and psychosis. MCT shares knowl- information, or do you we have is enough to Centre Hamburg- edge gained in research labs to help have enough to decide? decide, or whether Eppendorf in Germany. individuals experiencing psychosis we need more infor- Todd researches the become more aware of the thinking mation to decide. neural and cognitive 3 Can you now patterns involved in their illness. decide this is a rocking underpinnings of psychosis The training was developed Is it a: chair? and schizophrenia (and continues to be developed) smiling face? by Steffen Moritz at the University bowl? Medical Centre Hamburg-Eppen- 4 You’re correct, but dorf in Germany and myself. My boat? it was important that research, some of which is shared you waited to get all the sled? information before mak- through the MCT, has been carried ing a strong decision. out through the BC Mental Health rocking chair? and Addictions Research Insti- elephant head? Is it a: smiling face? bowl? boat? sled? rocking chair? elephant head? tute and the University of British excluded, improbable, possible, probable, DECISION Columbia. The first MCT manual was published in 2005. MCT is cur- rently used in more than 40 centres lucinations) is not a sudden and Common thinking distortions worldwide and has been translated instantaneous incident. It often include: into 14 languages. begins with a gradual change in • making strong judgments based The main purpose of the meta- one’s thinking and social environ- on little evidence cognitive training is to help people ment. Learning to be aware of one’s • blaming other people rather than change the thinking patterns that thoughts can help prevent psychot- circumstances cause delusions, thereby avoiding ic breakdown. • being unable to fully consider relapse into illness or reducing the The MCT is a group-based pro- and accept information provided impact of delusions. gram that teaches participants by other people about common thinking patterns to • being unable to let go of strongly How does MCT work? which they may be prone. The pro- held positions Research shows that people with gram also suggests ways to coun- • being overconfident that inaccu- schizophrenia or psychosis tend to ter these potentially problematic rate memories are in fact accurate think and reason in ways that can thought patterns. The MCT program aims to raise help establish delusions.1 Delusions Erroneous or distorted thinking clients’ awareness of these distor- are false beliefs that aren’t shared by patterns may—on their own or in tions and to prompt them to criti- others in the community. For exam- combination with other factors— cally reflect on, complement and ple, the belief that one is being spied help establish delusions. Processing change their current problem-solv- on by the CIA is (almost always) an emotionally charged information ing tools. example of a delusion through distorted thinking styles MCT never addresses partici- Psychosis (delusions and hal- may trigger delusional thoughts. pants’ specific delusions. However,

20 Visions Journal | Vol. 6 No. 1 | 2009 alternatives and approaches individual delusional themes can bution—Blaming be addressed in one-to-one thera- and Taking Credit; related resources peutic sessions, such as cogni- Jumping to Conclu- tive-behavioural therapy (CBT). sions I; Changing i TTResearch articles related to MCT Also, our new MCT+ program,* Beliefs; To Empa- www3.telus.net/Todd_S_Woodward/cognitive%20bias%20training.htm though based on our group MCT, thize I; Memory; TTComprehensive articles on the research behind the modules is more individualized and can To Empathize II; www3.telus.net/Todd_S_Woodward/metamemory.htm be used to supplement CBT Jumping to Conclu- www3.telus.net/Todd_S_Woodward/schizophrenia.htm (www.uke.de/mkt_plus). sions II; and Self- esteem and Mood. Program sessions The sessions are entertaining nitive program administered to a * There is currently only The program is provided in a group and designed to capture partici- control group.3 Voluntary partici- a beta version of MCT+ program structure because the gen- pants’ attention (see sidebar). Al- pation has been excellent, and the available in English; eration of ideas that results from though the exercises are fun, they participants tend to recommend otherwise it’s available participant interaction is key to the also challenge problem thinking the program to others. in German. learning process. patterns. Each cycle of the program is Though MCT is an interac- How can you participate made up of eight modules. Present- tive program, participants are not in a session? ing two modules per week, one pressured to be involved. They are The MCT program is not offered module each session, is helpful be- asked to participate at their own publically to a general audience. cause a full cycle can be completed comfort level. Members of your care team are en- in one month. There are also two Discussion about what type of couraged to access all the resources cycles of the program available. thinking underlies delusions is en- they would need to administer the They cover the same topics, but the couraged—but participants are not program themselves. A number of instructional content is different. required to discuss their individual care teams in the Lower Mainland This is so participants can repeat (possibly delusional) beliefs. are currently offering this program the training and have a fresh learn- to their clients. ing experience. How can you benefit MCT is available free of charge to footnotes Each session emphasizes the from MCT? any health professional running sup- visit heretohelp bc.ca/ learning objective of the module Early research suggests that MCT port groups for people with schizo- publications/visions (“Why are we doing this?”) and the produces a reduction in the sever- phrenia and psychosis. Information, for Todd’s complete 2 practical relevance to the individu- ity of delusions. And in a feasibility materials and program modules can footnotes or contact us al’s experiences (“What does this study, the MCT program was rated be accessed through the University by phone, fax or e-mail have to do with psychosis?”). as more fun and more useful in Medical Centre Hamburg-Eppendorf (see page 3) The module topics are: Attri- daily life than an alternative cog- (www.uke.de/mkt).

CBT for Children and Youth in BC bout one in seven—that’s 140,000—children and their families. Instead of focusing only on children Gayle Read and youth in BC have a mental health prob- and youth with the most serious mental disorders, the Alem serious enough to affect their relation- CYMH Plan focused on helping young people earlier, Gayle is the Senior Mental ships with family and friends and their performance to prevent or reduce their risk for developing mental Health Consultant on the in school. There is also a gap between the need and health problems. Additionally, the plan provided direc- Child and Youth Mental the availability of mental health services.1 The Ontario tion for the types of therapy that would be most likely Health Policy Team, Child Health Study in 1997 determined that only one to help children, youth and their families. Before the Ministry of Children and in six children and youth with mental disorders receive CYMH Plan, clinical services were a mixture of what- Family Development. She some form of specialized services.2 ever approaches staff clinicians had to offer. has worked in mental In developing the CYMH Plan, the Ministry of Chil- health for 26 years as a The Children and Youth Mental Health Plan dren and Family Development (MCFD) committed to us- clinician, supervisor, manager The Child and Youth Mental Health Plan for BC (CYMH ing research evidence to make sure the most effective and consultant. Gayle and Plan) was introduced by the provincial government in prevention and treatment approaches would be used. her colleagues developed February 2003. The five-year CYMH Plan (2003–2008) In 2001 to 2002, the Children’s Health Policy Cen- and implemented the Child presented a new approach to services and supports tre at Simon Fraser University reviewed the research and Youth Mental Health for children and youth with mental health problems literature on behalf of MCFD. MCFD also formed >> Plan for BC

Visions Journal | Vol. 6 No. 1 | 2009 21 alternatives and approaches

expert advisory groups expect to feel sad or depressed for a short period fol- some things you may do to recommend the best lowing a loss or disappointment. But if it lasts several approaches for some months, a mental health professional can help you as part of CBT are: particular mental health learn ways to deal with these feelings. problems. These in- Parents have a very important role to play in helping cluded depression, anxi- their children deal with anxiety or depression. Parents 3 Learn skills to help you relax and feel more in ety, behaviour problems can help by supporting their children to try new behav- control, such as deep breathing or meditation. and eating disorders. iours, gently questioning unhelpful beliefs, supervising Advisory groups also the charting of tasks and modelling positive behaviour. 3 Learn social skills to improve your sense of addressed co-occurring Cognitive-behavioural therapy has primarily been competence, including how to carry on a issues of mental health used for children and youth ages eight and older, but conversation with someone you just met. and substance use, and programs using the principles of CBT have been shown 3 Gradually expose yourself to situations that mental health and de- to be effective with younger children as well. FUN cause anxiety to learn that fears are often velopmental disabilities. FRIENDS, an anxiety prevention program for children exaggerated—first by thinking and planning to do Recommendations aged four to seven, is being piloted this fall in BC. It’s that activity, and eventually by doing it for a short led to training initiatives an adaptation of the original FRIENDS program that time. The length of time is gradually increased as as part of the CYMH Plan, MCFD and school districts have implemented in grades you feel more comfortable. focusing on cognitive-be- four, five and seven in BC. AnotherMCFD project based havioural therapy, inter- on CBT principles is the self-help depression manual 3 Chart task assignments and progress on personal psychotherapy, for youth titled Dealing With Depression: Antidepres- a daily basis. For instance, you could track the dialectical behavioural sant Skills for Teens. You can find all these programs number of times you are able to participate in an therapy, suicide and dual on the MCFD website (see sidebar next page). activity that makes you feel happy. diagnosis. Cognitive-behav- Expanding CBT services in the province ioural therapy (CBT) By 2005, MCFD had begun training CYMH clinical staff was recommended as the most effective approach for in CBT to ensure they could use the most effective ap- anxiety and depression. Anxiety is the most common proaches for helping children and youth with anxiety mental health problem in children and youth, affecting problems and depression. about 6.5% of young people. Depression affects 2.1% MCFD works with CBT Connections,3 a BC company of children and youth.1 that provides training. They offer a two-day foundation- al CBT workshop on the principles of CBT as treatment The CBT approach for anxiety disorders, including generalized anxiety, CBT is a counselling approach that requires the active obsessive-compulsive behaviour, phobias, separation participation of the client. It helps you understand the anxiety, panic, social anxiety and post-traumatic stress. connections between your thoughts, feelings and be- The goal is to have all MCFD clinicians in the province haviours that might contribute to anxiety and depres- take the two-day workshop. Registration for each training sion. session is based on population and socio-economic fac- Feelings of anxiety are learned, so fortunately they tors to ensure there are trained clinicians province-wide. can also be unlearned. These feelings are often reinforced There are approximately 500 clinicians in BC, and at through direct and indirect experiences. For instance, present, about three-quarters have done this training. growing up with a parent who is overprotective or having Clinicians can complete a certification program fearful experiences like being bit by a dog may reinforce through CBT Connections and AnxietyBC. In addition the notion that the world is a scary place. to the two-day workshop, they learn in more depth A question a clinician might ask to help you look at how to use CBT with children and youth who have more some of your anxious thoughts or beliefs could be: Do complex anxiety disorders. This latter part of the pro- you notice that when you think that bad things are go- gram involves Web-based learning modules and tests, ing to happen, they almost never do? When people with developing case treatment plans and making audio anxiety experience physical sensations like a racing heart recordings of client sessions for feedback by trainers. or sweaty hands, they often fear they might faint or have Almost half of all CYMH clinicians have completed a heart attack. These physical sensations, however, are the CBT certification for anxiety disorders. There isn’t a seen by mental health professionals as normal reactions requirement for all clinicians to complete the certifica- to scary situations. They are not dangerous and often last tion, though all are encouraged to do so. Some clinicians, footnotes visit heretohelp bc.ca/ for only a very short time, then go away. The clinician’s however, choose to focus additional training on one of the publications/visions task is to help you realize this and devise strategies for other approaches recommended in the plan instead. for Gayle’s complete managing your reactions to these sensations. Some CYMH clinicians have also received addition- footnotes or contact us Similarly, in the case of depression, a clinician al training in CBT for depression (by Dr. Chris Wilkes, by phone, fax or e-mail might ask: Have you felt this way at another time in Head, Child and Adolescent Psychiatry in the Calgary (see page 3) your life, and did those feelings go away? One would Health Region), though there are no plans for further

22 Visions Journal | Vol. 6 No. 1 | 2009 alternatives and approaches training at this time. The principles, however, are simi- lar to those applied to anxiety disorders. where to find the resources in this article A small group of CYMH clinicians have received training in Trauma-Focused CBT delivered by the Har- i borview Center for Sexual Assault and Traumatic Stress4 TTChild and Youth Mental Health Plan for BC in Seattle. They will be better able to help children and www.mcf.gov.bc.ca/mental_health/mh_publications/cymh_plan.pdf youth who have experienced trauma in their lives. There TTChildren’s Health Policy Centre (SFU) reviews are plans for further training in this area of CBT. www.childhealthpolicy.sfu.ca/research_reports_08 TTFRIENDS program Accessing CBT www.mcf.gov.bc.ca/mental_health/friends.htm MCFD offers free counselling, including CBT, to children and youth with mental health problems and their fami- TTDealing With Depression: Antidepressant Skills for Teens lies. You can access CBT by accessing counselling serv- www.mcf.gov.bc.ca/mental_health/teen.htm ices through MCFD. TTChildren and Youth Mental Health offices If you have concerns and would like to speak to a www.mcf.gov.bc.ca/mental_health/pdf/services.pdf mental health clinician, check the MCFD website (see sidebar) for the Child and Youth Mental Health office closest to you. You can also find office locations in the provincial services section of your telephone directory blue pages.

CBT: Does it work well with the Chinese population in Vancouver?

UCCESS is a multi-service • it’s practical—clients are asked to ing about their emotions. Emotions Mary Kam, MSc, RCC agency with a mandate of do homework and assignments tend to be conveyed in terms of promoting the well-being All these characteristics work physical complaints or complaints Mary is a clinical of all Canadians and immigrants. well with most Chinese families. about family members. counsellor. She is the SThe organization has offered coun- Very often, Chinese clients who Chinese families also have Senior Manager of selling services to the Chinese great respect for experts and au- SUCCESS Family and community for over 30 years. thority. Because of this, a direc- Youth Services Division Cognitive-behavioural counselling tive counselling approach by an in Vancouver. Mary also (CBT) is widely used by our thera- authority figure is well received. provides frontline clinical pists because it works well with Moreover, Chinese clients prefer counselling to immigrants many clients of Chinese cultural an educational model because background. they are used to playing the “stu- Kelly Ng, MSW, RSW dent” role while the therapist plays CBT and the the “teacher” role. Kelly joined SUCCESS Chinese population in 1992 as a Program Most cognitive-behavioural therapies Changeways: Director, heading the have the following characteristics: adapted for SUCCESS largest Chinese-speaking • emotional response is looked at Changeways (changeways.com) is counselling team in from a cognitive or thinking per- an evidence-based group program, Western Canada. He spective originally developed by Vancouver conducted the first • therapy is brief and time-limited come to counselling expect a quick psychologists in 1991 for patients Changeways stress • therapy is structured and pro- fix to their problems, expecting prac- who had recently received hospital management program vides direction and guidance tical and immediate solutions. They care. Changeways has since been for immigrant men in the • therapy uses a teaching–learning are also more used to an analysis of revised and is now offered to seri- Chinese community. Kelly is approach their problems based on concrete ously depressed people by hospi- currently on the Child and • facts and rational interpretation evidence rather than the sharing of tals (on an outpatient basis) and Youth Advisory Committee are used to help clients under- deep-seated feelings. Many Chinese community agencies like SUCCESS. for the Mental Health stand issues clients don’t have experience talk- Its approach is primarily >> Commission of Canada

Visions Journal | Vol. 6 No. 1 | 2009 23 alternatives and approaches

cognitive-behavioural, and the pro- our recommendations for making The SUCCESS experience: gram uses an adult education mod- the Changeways Core Program for a good fit el to teach participants a variety of depression culturally more relevant. The program received overwhelm- self-care skills. These include set- The program content was slightly ingly positive response from the ting sustainable goals, relaxation modified to suit the learning style community. Most groups were full, techniques, assertiveness skills of Chinese participants, and cultur- with a waiting list. and rebuilding their social net- ally relevant metaphors were added In our estimation, Changeways work. The program covers a range (see sidebar). has been well-received by the Chi- of topics, including the CBT aspects We offered the program to nese participants because its psy- of the interconnected triangle of the adult Chinese community cho-educational model fits well thoughts, emotions and behaviour, from 2000 to 2007, calling it the with their preferred “student” role and styles of distorted thinking. Changeways Stress Management and learning style. The relaxation Stress and depression, sustaining Course. To address stress, relaxa- exercises they learned in the ses- lifestyle and assertiveness are also tion exercises from the Change- sion and practised at home were covered. They help the individual ways Relaxation Program were practical. The paper-and-pencil develop positive thinking and be- added to each session. exercises in the participant hand- havioural outcomes. We ran five groups for men and book were another concrete activ- Changeways Clinic director Dr. seven groups for both men and ity. The ‘lectures’ on facts, theories Randy Paterson assisted in training women. We targeted the program and specific topics provided a con- our facilitators. He also endorsed more at men because it’s generally crete base from which participants much harder to engage them could draw on relevant personal life in training programs. We also experience and take part in group wanted to encourage them to discussion. cultural metaphors used in develop social support; wom- Since Changeways is CBT SUCCESS’ changeways program en generally have less problem based, it follows that CBT is com- reaching out to others. patible with the expectations of our Participants used a slight- Chinese clients. CBT is psychoedu- ly adapted version of the cational (helps people learn about The Chinese character of “tolerate” 忍 Changeways participant hand- mental illness) and promotes self- The traditional Chinese culture emphasizes maintaining book that was translated into help. Chinese clients welcomed harmony in human relations. This results in tolerance of unfair Chinese. the teaching of new coping skills to treatment, especially by those in authority, to the point of Feedback from the par- manage stress problems. The flex- depression for some people. The Chinese character “toler- ticipants—from self-reporting ible structure of CBT also allowed ate” resembles a knife over the heart. We put ourselves at risk forms that are integral to the us to incorporate the many factors if we tolerate too hard and for too long. The knife will stab Changeways program—re- related to cultural background and into our heart and cause bleeding. The only way out is to take vealed that many aspects of immigration that affect the psycho- away the knife—be it thought or emotion—that deeply hurts the program were very rele- logical well-being of our clients. us as we plunge into depression. This can be achieved by vant to their needs. It’s never our intent, however, to learning new coping strategies. The practical relaxation generalize our observations to the exercise in each session, the diverse Chinese population in Van- The “toothpick container” facilitated group discussion, couver. Many factors, such as years Toothpicks cannot come out of the container if too many of participant manuals in Chi- of living in Canada, place of birth, them are packed together inside. We have to drop or let go of nese and “teaching” how to level of integration and former ex- some of them, or else the toothpick won’t be able to fulfill the overcome negative thoughts posure to Western education may function it’s designed for. An important stress management were all rated highly. all affect how clients interact with strategy is not to allow stress to accumulate. Seek help when The introduction to the different counselling approaches. signs and symptoms of stress begin to arise; don’t wait. And concept of assertiveness— SUCCESS could not fund the instead of being entrenched in chronic worry, we can isolate a concept that has no direct Changeways program after 2007, the worry to certain times of the day; that is, deal with one translation in Chinese—was but we plan to offer it again if we “toothpick” a time. highly relevant to partici- can find a funding source. We con- pants’ needs. We framed it sistently receive requests for this 危機 The Chinese meaning of “crisis” as “standing firm” with one’s program. opinion and values while not For more information on the It means there’s a new opportunity behind the danger/risk. offending others. Immigrant counselling programs currently of- The experience of depression and of joining the Changeways participants also found it very fered at SUCCESS (which include program helps us adopt new ways of achieving a healthy life helpful to evaluate the experi- counsellors who use CBT), visit balance. ence of having a shrunken so- www.success.bc.ca and click on cial network. “Counselling” or “Family.”

24 Visions Journal | Vol. 6 No. 1 | 2009 regional programs

Cognitive-Behavioural Therapy for Adults With Mental Health Problems Working to improve access in BC ccessing cognitive-behavioural therapy (CBT) is result is high rates of untreated mental health prob- Jamie Livingston, not easy for many adults in British Columbia lems in the province. BC Mental Health & Awho have mental health problems. Because of BC does not currently have a system in place to Addiction Services this, BC Mental Health & Addiction Services (BCMHAS), train, supervise and accredit mental health profession- (BCMHAS), Provincial an agency of the Provincial Health Services Author- als in CBT. And the CBT expertise that is available in Health Services Authority ity, formed the BC Cognitive Be- BC is unequally distrib- (PHSA) haviour Therapy Network in late uted across the province, 2008. The intent is to improve as services tend to be Mark Lau, BCMHAS, PHSA access to CBT across the province concentrated in urban and to strengthen province-wide areas. This creates count- Dolores Escudero, collaboration. less missed opportunities Ministry of Health The BC CBT Network is to intervene with adults Services made up of clinical and admin- before mental health istrative representatives from problems become severe, Eric Ochs, Vancouver BCMHAS, the Ministry of Health debilitating and costly. Island Health Authority Services (MoHS), the Ministry of We know that we need Children and Family Develop- to work hard across BC to Gayle Read, Ministry ment and each of the five re- improve the availability, of Children and Family gional health authorities. These accessibility and afford- Development representatives meet regularly ability of CBT services for to advise and coordinate ini- adults who have mental Pam Whiting, tiatives to build CBT capacity health problems. BCMHAS, PHSA throughout BC. The work of the BC CBT Net- For many mental health What is low-intensity Maureen Whittal, work is guided in part by a pro- “problems, CBT is as CBT and how do you Vancouver CBT Centre vincial CBT service framework access it? that was drafted by BCMHAS effective as medications People often think of Chris Wilson, Interior and MoHS in early 2009.1 This CBT as face-to-face, Health Authority framework outlines a broad-based plan for strengthen- one-on-one counselling. However,” low-intensity CBT ing CBT services in BC. emphasizes self-help and can be highly effective for The contributing authors The vision of the BC CBT Network is that every per- many people who experience mild to moderate levels are all founding members son in BC will have equal access to high-quality CBT, of distress. There are two types of low-intensity CBT: of the BC Cognitive no matter where they live. This will lead to better care pure self-help and guided self-help. Behaviour Therapy and treatment for people with mental health problems. Pure self-help refers to people managing their men- Network tal health problems on their own. They learn about What do we know about CBT coping skills and strategies through books, workbooks, services for adults in BC? DVDs, computer software or Internet-based programs. We know that CBT is an effective psychotherapy for treat- Guided self-help refers to people learning about and ing a wide range of mental health problems. For many using CBT strategies with the guidance and support of mental health problems, CBT is as effective as medica- a trained professional, such as a general practitioner tions and more cost-effective over the long term.2-3 (GP) or community coach. Bounce Back: Reclaim Your However, we also know that BC doesn’t have Health is one example of a BC program that uses a enough professionals trained in CBT to meet the needs guided self-help approach.* of the people. Therefore, medications continue to be In BC, you may be able to obtain information the primary or sole method for treating mental health about low-intensity CBT resources through your GP. Ef- * For more information on problems in BC. Since some people don’t want to take forts are underway to provide BC physicians with CBT the Bounce Back program, psychiatric medications and some can’t afford to, the training and resources so that they can identify, >> see the article on p. 31

Visions Journal | Vol. 6 No. 1 | 2009 25 regional programs

guide and support patients with ance program or by contacting a local psychotherapist mental health problems.4 The through a professional organization (see sidebar). Antidepressant Skills Workbook5 and the Cognitive Behavioural In- Choosing a CBT practitioner terpersonal Skills Manual6 are ex- When choosing a practitioner in BC, it’s important to amples of self-help CBT resources know that it’s unlikely they will be accredited in CBT. that some physicians are using. At In fact, no Canadian province or territory has estab- present, however, many GPs may lished standards for accrediting CBT practitioners. Only be unaware of low-intensity CBT a small number of trained CBT practitioners in BC are resources. You can also get infor- accredited through the US-based Academy of Cognitive mation from either a non-profit Therapy, which is the only registry of accredited CBT mental health agency (such as the practitioners in North America. Canadian Mental Health Associa- The BC CBT Network is working towards estab- tion) or through the Internet. lishing standards for accrediting practitioners that Internet based examples of low-intensity CBT that provide CBT services in BC. But for now, there is no can be accessed at no cost include the self help resourc- easy way for people who are seeking treatment to es listed in the sidebar. The BC CBT Network is currently find out how qualified or skilled a particular practi- working with several non-profit mental health agencies tioner is in CBT. (e.g., AnxietyBC, Canadian Mental Health Association’s Some useful background questions to ask before BC Division) to increase awareness of and access to low- you decide to receive CBT from a particular practition- intensity CBT resources in BC. er may include whether they’ve received specialized training in CBT, how long they’ve been providing CBT What about high-intensity CBT? and how much experience they’ve had treating peo- High-intensity CBT refers to formal, face-to-face serv- ple similar to yourself with CBT. It’s also important to ices delivered by a trained therapist, such as a clinical check how much financial coverage your workplace psychologist or counsellor. These services are gener- employee assistance program or extended health plan ally suited to people with moderate to severe levels of provides for CBT. distress related to mental health problems. In BC, high-intensity CBT for adults is provided in either the public or private health care sectors. As men- tioned earlier, high-intensity CBT services in the public how to find CBT resources health sector are difficult to access in BC. You can con- i tact your local GP, nurse practitioner or mental health service provider to ask how to get information about Free online low-intensity CBT resources these services, whether high-intensity CBT services are TTwww.bcmhas.ca/Research/ASW available in your area and, if so, whether you qualify TTwww.anxietybc.com/resources/introduction.php footnotes to access these services. A long-term goal of the BC TTwww.heretohelp.bc.ca/skills visit heretohelp bc.ca/ CBT Network is to dramatically increase the number of TTwww.changeways.com/scdpintro.shtml publications/visions practitioners in the public health sector who are appro- TTwww.comh.ca/antidepressant-skills/adult for the authors’ TTmoodgym.anu.edu.au complete footnotes priately trained to provide high-intensity CBT. TTecouch.anu.edu.au or contact us You can also find out more about the cost and TTwww.livinglifetothefull.com by phone, fax or e-mail availability of high-intensity CBT in the private health (see page 3) sector through your workplace employment assist- Find a professional to help TTBC Association of Clinical Counsellors www.bc-counsellors.org TTBC Psychological Association www.psychologists.bc.ca TTBC Association of Social Workers www.bcasw.org TTAcademy of Cognitive Therapy www.academyofct.org TTAssociation for Behavioral and Cognitive Therapies www.abct.org TTCounselling BC www.counsellingbc.com

26 Visions Journal | Vol. 6 No. 1 | 2009 regional programs

Help With Mild to Moderate Depression CBT-based self-management options

s a psychologist in an emer- for support to develop new kinds in reaching your life goals and Dan Bilsker, PhD, RPsych gency psychiatric unit, I’ve of self-management materials and may cause suffering A seen thousands of people in training. Fortunately, it has been 3. These patterns can be changed Dan is a psychologist who depressive crisis. I have developed possible to gain the support of vari- through learning coping skills in provides consultation to an approach to help these individu- ous BC health care agencies in de- the therapy situation, trying out the Centre for Applied als who struggle with the bitter suf- veloping and distributing self-man- these skills in your own life and Research in Mental fering of dark mood and despair. It agement tools and related training. practising new coping patterns Health and Addiction at teaches what is known about de- These agencies include the Pro- SFU. He also works in an pression as well as problem-solving vincial Health Services Authority, Our self-management workbooks emergency psychiatric strategies.1 BC Ministry of Health Services, BC closely track current research evi- unit at Vancouver General About 10 years ago, it dawned Ministry of Children and Family dence regarding effective CBT treat- Hospital. Dan oversees an on me that if the highly depressed Development, Vancouver Coastal ment principles. The CBT-based ongoing project to enhance patients I was seeing in the hos- Health, BC Medical Association skills are clearly explained and mental health care pital didn’t have basic knowledge and Michael Smith Foundation for taught in a step-by-step way. The through brief behavioural about depression, it was likely that Health Research. workbooks include writing exer- interventions for mood people with less severe depression Our CARMHA research group cises, specific goal-setting and il- disorders didn’t have this knowledge. This has developed two basic approach- lustrative stories that demonstrate struck me as fundamentally wrong. es to making self-management application of the skills. Surely our health care system could knowledge and skills available to deliver basic knowledge and skills the general public. The four workbooks are described for dealing with one’s own mood. below. Surely we could teach mood self- Self-management workbooks • Antidepressant Skills Workbook management. We have developed four self-manage- is our basic depression >> From the moment I recognized ment workbooks. They are free, eas- this gap in mental health services, I ily accessible, consistent committed to getting knowledge and with research evidence, a supported self-management scenario skills for mood self-management to brief and easy to use. people who were depressed. The workbooks are based on CBT principles Thomas, a 25-year-old man, reports to his family physician that he’s Mood management: for the management of been feeling fatigued and low in mood. He’s also been avoiding so- CBT to the rescue depressed mood. CBT cial gatherings over the few months, since a relationship ended. The A solid body of research shows that focuses on identifying physician diagnoses a mild depression. Knowing that antidepressant providing cognitive-behavioural ther- problems with an indi- medication is not recommended for mild cases due to low effective- apy (CBT)-based self-management vidual’s behaviour and ness in relation to side effects, the physician provides supported material to people dealing with mild thinking, then teaches self-management. depression is an effective interven- evidence-based skills for In the first session, the physician briefly explains theCBT model of tion.2 There’s also good evidence coping more effectively. depression, gives Tom a copy of the Antidepressant Skills Workbook that adding the element of support It deals with current life and encourages him to read the “Behavioural Activation” section. increases the positive impact of self- challenges and stresses, In a second session a week later, the physician helps Thomas set management workbooks.3 rather than exploring some initial activation goals, including scheduling a time to contact The existing self-management childhood experiences. a friend he hasn’t seen for a few months. workbooks were either costly, incon- It is based on that the The physician and Thomas have four more sessions over the next sistent with available research, too idea that: couple of months, focused on encouragement and help with goal wordy or just not clearly written. 1. People learn thinking setting. Thomas uses the behavioural activation to re-establish con- As a scientist in the Centre for and behavioural cop- nection with friends and family as well as to resume some rewarding Applied Research in Mental Health ing patterns through- activities he had dropped. His depression lifts. and Addiction (CARMHA) research out their lives Thomas continues to use these skills in subsequent years to man- group at Simon Fraser University, 2. Some of these pat- age his mood. I created partnerships and looked terns are ineffective

Visions Journal | Vol. 6 No. 1 | 2009 27 regional programs

self-management workbook for tured problem-solving (see cians would in fact make use of this adults. sidebar) intervention with their depressed It provides: • Antidepressant Skills @ Work patients. We delivered a brief and || information on how difficult is the basic self-management very practical training session in situations, depressive thinking workbook adapted to the chal- supported self-management to a styles, avoidance behaviour, lenges of dealing with mood large number of family physicians. inactivity and other factors problems in the workplace. It in- The result was very reassuring—this can make depression worse cludes information on the effects group of physicians delivered the || of depression on work perform- intervention to a substantial propor- footnotes an overview of effective treat- ance—and the impact of work- tion of their depressed patients.4-5 visit heretohelp bc.ca/ ment for depression publications/visions || an explanation of three self- place stress on depression. It The physicians in our study, and for Dan’s complete management skills that are also helps with making decisions many others we’ve since trained, re- footnotes or contact us helpful for managing depres- such as whether to take time off port this intervention to be a useful by phone, fax or e-mail sion: behavioural activation, from your job. addition to their practice. (see page 3) realistic thinking and struc- • Dealing With Depression is a ver- An important feature of sup- sion of the depression self-man- ported self-management is that it agement workbook designed for can be carried out in brief visits. 3 self-management skills teens. The time pressure on family phy- • Positive Coping with Health Condi- sicians results in typical patient tions is a mood self-management visits of 10 to 15 minutes. Intro- Behavioural activation workbook for people suffering ducing patients to the self-man- Depressed people typically become less active. from chronic illness. It teaches agement workbook, explaining its They withdraw from social contacts, reduce skills for dealing more effectively relevance and supporting use of their level of self-care activities and become less with depression, anxiety, anger the skills can be done in a series active in hobbies or other activities. It may seem to the and social isolation in the con- of brief visits. depressed person like a way of conserving strength, but text of health conditions. What’s crucial is that the pa- inactivation typically worsens the depressed mood and tient is reading and using the work- slows recovery. In behavioural activation, target activities Each workbook is available for book between physician visits—in are identified. The person is encouraged to make an free download from our website at fact, most of the important learning activation plan that is specific, realistic and scheduled. www.carmha.ca/selfcare. Printed and change occurs in the patient’s copies are also available at a mod- life outside of the clinic. Realistic thinking est cost through a print-on-demand It must be kept in mind, how- This skill addresses the cognitive side of service, contacted through our ever, that for more serious depres- depression—depressed people often think about website. These workbooks have sion cases, supported self-manage- themselves and their situation in an unrealistically negative been distributed to approximately ment will not be enough. CBT for way. This can show up as harsh and unfair self-criticism, 95,000 people. more serious cases requires refer- a pessimistic approach to the current situation and ral to a CBT psychologist (or other unrealistically negative expectations for the future. The Supported self-management provider well-trained in CBT). Still, depressed person is shown how to identify these types Supported self-management is supported self-management can be of depressive thinking. Then the person is shown how to provided by trained primary care used along with other treatments challenge these depressive thoughts and come up with practitioners such as family physi- such as medication or treatment by a set of alternative thoughts that are fair and realistic. cians or primary care nurses. They a CBT clinician. Fair and realistic thoughts must be practised in situations provide access to the self-manage- where the depressed person normally would think in a ment workbooks, explain the CBT Self-management and supported harsh and negative manner. approach, encourage the patient self-management have the potential to give it a try and help the patient to transform care for mild to mod- Structured problem-solving to set self-management goals (see erate depression. Family physicians Depressed people may have considerable sidebar). are pleased to be able to deliver CBT- difficulty solving problems. They tend The physician or nurse is not based interventions to many of their to overestimate the severity of the problem and required to become a CBT psycho- depressed patients. This extends underestimate their personal resources. In structured therapist, which requires consider- the physician’s reach and improves problem-solving, the person starts by identifying a able training and a great deal of quality of care without significant particular problem, one that is not too difficult. Then they clinical time. Instead, the health new health care resources. And pa- write out three possible actions and the advantages or care provider acts as a coach, en- tients welcome this new level of ac- disadvantages of each. They then choose one action couraging and assisting patients. cess to mental health care. and make a plan. As problem-solving skills improve, more At CARMHA, we conducted a difficult problems can be addressed. research trial several years ago to To download the workbooks, visit determine whether family physi- www.carmha.ca/selfcare.

28 Visions Journal | Vol. 6 No. 1 | 2009 regional programs

Taming Worry Dragons Helping children and youth cope with anxiety

in schools and mental health programs for children Noel Gregorowski, MSW throughout BC and across Canada, including at the Children’s Hospital of Eastern Ontario and London Noel is a social worker and Health Sciences Centre. It includes Worry Taming for therapist at the Mood and Teens, written for youth using language and analogies Anxiety Disorders Clinic that appeal to this age group.2 The Kid’s Guide to Tam- at BC Children’s Hospital, ing Worry Dragons is a pocket-sized book that was where she does individual developed for classroom use,3 along with a classroom and family work with manual for teachers. children and adolescents. Noel is involved in Training junior knights organizing and running the Taming Worry Dragons is a creative approach to CBT Taming Worry Dragons, as and psychoeducation (teaching about mental health well as an interpersonal illustration: Vicky Earle conditions) that is designed to help anxious children therapy group for older learn how to cope with their worries. The approach can teens be adapted by therapists and parents to match the de- velopmental level and interests of the child involved. We start by positively reframing anxiety prob- E. Jane Garland, lems. Anxiety is presented as a combination of a “tal- MD, FRCPC ent for creative worrying” and an “oversensitive body alarm system” that work together to magnify worry Dr. Garland is a Clinical ow, you have an amazing imagination! I couldn’t and distress. Professor of Psychiatry at “Weven have thought of that many things that Anxious children may instinctively avoid their dif- UBC and Clinical Head could go wrong! I wonder if you could use your amazing ficulties—the hardest part is actually facing their fears. of the Mood and Anxiety imagination to come up with some solutions.” In the worry dragon approach, the child externalizes Disorders Clinic at BC – Dr. Garland, in session with a young client the problem and views anxiety as separate from him or Children’s Hospital. She her self. A young dragon tamer in training shares in the is actively engaged in Imagine: from therapist to junior knight trainer process of naming anxiety—worry dragon, bully, worry research, teaching and In the early 1990s, Dr. Jane Garland imagined adapt- virus or whatever appeals to the child’s imagination. consultation. Her focus is ing cognitive-behavioural therapy (CBT) to better serve The child teams up with their parents and thera- on psychopharmacological anxious children. CBT is known to be effective for anxi- pist to gradually face fearful situations. They start with and cognitive-behavioural ety, but it can be difficult to motivate children to prac- the easier ones (playing at a friend’s home with their treatment of mood and tise the essential skills. own mother present) and build up confidence to tackle anxiety disorders in young Inspired by one of her young patients, Dr. Garland more challenging ones (the sleepover birthday party). people developed a more playful model of CBT: training a junior Verbal (praise) and concrete rewards (such as a star knight in “taming worry dragons.” When the Mood and chart or Lego pieces) for brave behaviour can help this Anxiety Disorders Clinic was developed at BC Children’s process move along. Hospital in 1994, Dr. Garland teamed up with Dr. Sandra The imaginative model helps children commit to Clark, a child psychologist with expertise in CBT. Togeth- making changes. It’s fun, interesting and they experi- er, they developed these ideas into an engaging group ence a sense of success as they move forward. program and training manual to help children and par- Children learn imaginative tools to trap the wor- ents cope more effectively with anxiety. ries that are “bossing them around.” Typical tools in- With funding from a Children’s Hospital Foun- clude trapping the worries (putting them into a worry dation Telethon grant, the first Taming Worry Drag- jar or confining them to a planned worry time) or im- ons manual was published in 1995.1 It became very agining that you’re pressing the stop button on the popular with both professionals and families. A chil- worry machine. dren’s workbook, therapist manuals and training They also learn tools to tame the worries so that videos followed. their feelings and thoughts become helpful signals The Taming Worry Dragons program is now used rather than things that make problems bigger. >>

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and have some fun and balance their lives. Kids also listening to your MATH?? Yah, right know that to face a challenge, you have to practise to dragons build up the “coping muscles.” Popular fantasy books buddy. Forget it. YOU will like the Harry Potter series or movies about the young never pass!!! King Arthur give children plenty of role models for the real work it takes to develop their dragon-taming skills. Each week there are skills to practise and ex- periments or “detective” work to do (see example to the left).

‘Round tables’ of young knights and ‘orders’ of parents Groups are an efficient, cost-effective way to teach chil- dren to understand and manage their anxiety, and for them to realize that they’re not alone in this problem. The controlled, encouraging peer setting can engage some of the more reluctant and socially anxious chil- dren in practising skills. There is evidence that children with anxiety do better when their parents are supportive and can rein- le force the coping skills and practice at home. Therefore, Vicky Ear there is usually a parent group at the same time as the

Illustration: children’s group. This makes economic sense because parents need come to the clinic anyway to bring their children. We find that parents have often also been held hostage (i.e., are unable to go places, are afraid to have expectations for their child) by the child’s worry Ask yourself: What are my worry dragons? Make a list right now. dragons and need encouragement to make changes to Writing them down can even make them less scary than when they support their child. run around in your head. Think to yourself “I am afraid…” and see Taming Worry Dragons groups are held at the BC what comes up. Think to yourself “I am worried…” and see what Children’s Hospital outpatient clinic. They are also held comes into your mind. The more you know about these worries, the in many BC communities through the children’s men- less the dragons can push you around. tal health teams and other agencies.

Excerpted from Taming Worry Dragons: A Manual for Children, Parents, and Other Coaches by E. Jane Garland and Sandra Clark; illustrated by Vicky Earle.

Taming the worries requires more sophisticated tools. Taming means investigating and challenging the self- taming worry dragons resources critical messages or the bad predictions of the worry thoughts, and then developing more realistic thinking. i Children begin to understand that our minds con- Taming Worry Dragons materials are avail- stantly come up with new thoughts, but these thoughts able through the C&W Bookstore: are not reality. They learn to be curious about their own thinking process and learn how to evaluate the Ambulatory Care Building, Room K2-126 worrisome thoughts that arise. Children’s and Women’s Health Centre Children also learn to befriend their own body re- 4480 Oak Street, Vancouver actions. They come to appreciate how a strong physical 1-800-331-1533 local 3 or response like a fast heartbeat, muscle tightness or fast 604-875-2345 local 7644 breathing can be a useful process in the body. They [email protected] footnotes learn how these responses can be helpful for a crisis edreg.cw.bc.ca/BookStore/public/bookstore visit heretohelp bc.ca/ publications/visions situation or playing sports. But they need to be able to Contact information for AnxietyBC and local for Noel amd Jane’s calm and relax their bodies as well. They learn to use complete footnotes breathing strategies, visualization and/or progressive children’s mental health teams is available through or contact us muscular relaxation to help them calm down. the Kelty Resource Centre by phone, fax or Children can recognize that a dragon tamer in www.bcmhas.ca/keltyresourcecentre e-mail (see page 3) training needs to get enough sleep, eat well, exercise

30 Visions Journal | Vol. 6 No. 1 | 2009 regional programs

Bounce Back: Reclaim Your Health epression and anxiety are Bounce Back is now available to all program. Their role is to teach new Kimberley McEwan, the most common of all patients with mild to moderate de- skills, help patients stay motivated, PhD, RPsych mental health problems. pression and anxiety, whether or not answer questions and monitor pa- While everyone has bouts of low they have a physical health condition. tients’ progress. Kimberley is a moodD and excessive worrying, The program is delivered The program is based on the psychologist and these are temporary for most of us. through branch offices of the CMHA Overcoming Depression and Low consultant. She has For others, however, the feelings and is now offered in 17 locations Mood series2 of structured work- provided consultation don’t go away on their own and for- around the province (see sidebar books. The workbooks provide for several projects mal help is needed. next page). clear information and exercises to that focus on mental Many people are reluc- help people alter the way health and primary care. tant to take medications for they think and act in order to Currently, Kimberley is their mental health prob- bring about positive changes the Provincial Project lems, but family doctors in how they feel. Manager for the may feel they have little else Both forms of CBT help Canadian Mental Health to offer their patients. are available at no cost to pa- Association BC Division’s One very effective treat- tients. The DVD is available Bounce Back program ment, however, is cognitive- through your family doc- behavioural therapy (CBT). tor’s office. To access the tel- CBT has been shown to be ephone coaching program, a as effective as medication referral from your doctor is in the treatment of anxiety required. and depression.1 Unfortu- Coaching typically in- nately, CBT is not readily volves three to five telephone available for doctors to access for sessions with a Bounce Back coach, their patients. There are long wait- Bounce Back: which you can do in the comfort of lists for mental health services and what does it offer? your home. a limited number of mental health Bounce Back offers two forms of clinicians who specialize in CBT. CBT help. Both are based on the Bounce Back coaches: work of Dr. Chris Williams at the what? who? how? when? More help for more people University of Glasgow in Scotland. Research has demonstrated the In 2007, the Ministry of Health The first is a self-help DVD titled benefits of guided self-help CBT Services awarded a grant to the Living Life to the Full. It provides interventions.3 The same research taming worry dragons resources Canadian Mental Health Associa- clear tips and strategies to manage found that guided self-help pro- tion BC Division (CMHA BC) to de- your mood. The 45-minute DVD was grams don’t need to be delivered velop CBT services to support family originally filmed in Scotland and by a psychologist—they work just doctors in providing mental health has been adapted for BC. It covers a as well when provided by a para- care. The goal of the grant was to number of the most useful CBT skills professional. In cases of severe increase the availability of CBT. that people can learn to get more mood and anxiety conditions, how- Through this funding, the Bounce enjoyment out of life. The DVD is ap- ever, specialist care is required. Back program was developed. propriate for those who aren’t ready Bounce Back coaches are not The provincial launch of Bounce for a more structured intervention mental health specialists. Coach- Back took place in the Okanagan in like individual therapy. es come from a variety of back- June 2008. The program works with The second is a telephone-deliv- grounds, such as nursing, medical health authorities and other com- ered service. Bounce Back employs office assistance and social work. munity partners to help primary 20 community coaches who offer The coaches attend a manda- health care providers respond to guided self-help over the phone to tory three-day learning session on the very large number of patients support people with mild to mod- the CBT tools before they deliver in need of mental health assistance. erate depression and/or anxiety. services in their local community. It was initially designed to support The coaches support patients who Training is delivered by BC-based individuals living with a chronic are working through an effective, registered psychologists with CBT disease or chronic pain. However, short-term mood improvement expertise. >>

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After formal training, coaches Bounce Back: results to date a valuable community mental have weekly telephone consulta- Bounce Back has distributed over health resource. tion sessions with a psychologist. 18,000 self-help DVDs and nearly The success of the Bounce This provides the coaches with 2,000 referrals have been made to Back program is being evaluated by clinical support regarding cases the program for telephone coach- independent consultants. An effec- and reinforces their CBT knowledge ing. Program data from a provincial tiveness study is also planned. Re- footnotes visit heretohelp bc.ca/ and skill development. In addition, database shows that program par- sults will be available in 2010. publications/visions coaches make audio recordings of ticipants generally experience im- Bounce Back provides a CBT for Kimberly’s complete telephone sessions with clients. proved mood, reduced anxiety and intervention with the potential to footnotes or contact us These recordings can be reviewed enhanced quality of life. reach a very large segment of the by phone, fax or e-mail by the psychologists to ensure pro- This is what would be expect- population troubled by depression (see page 3) gram quality. ed through guided self-help CBT and anxiety. interventions. Early information from family doctors also shows For more information, see Bounce Back communities that Bounce Back is considered www.bouncebackbc.ca.

Bounce Back is being delivered through CMHA branches across BC, serving the following communities and surrounding areas:

q Cariboo/Chilcotin (Williams Lake) q North and West Vancouver q South Cariboo (100 Mile House) q Cowichan Valley (Duncan) q Port Alberni q South Fraser q Kamloops q Prince George q Vancouver/Burnaby q Kelowna q Richmond q Vernon q Kootenays q Shuswap/Revelstoke (Salmon Arm) q Victoria q Mid-Island (Nanaimo) q Simon Fraser

The first step of Bounce Back, the DVD, can be made available anywhere in BC, no matter how small the community. To find out if your community is served by the telephone coaching component of the program, call 1-866-639-0522.

Are you an immigrant or refugee with a mental health or substance use story to share? Our Winter issue of Visions will deal with mental health and substance use issues and experiences of seniors who are immigrants and refugees and their families.

If you have a story idea, please contact us at: [email protected] or call 1-800-661-2121

c/o 1200-1111 Melville St., Vancouver, BC Canada V6E 3V6

32 Visions Journal | Vol. 6 No. 1 | 2009