SEVEN PEARLS FOR EFFECTIVE COGNITIVE BEHAVIORAL THERAPY

SEVEN PEARLS FOR EFFECTIVE COGNITIVE BEHAVIORAL THERAPY


Research has proven that by identifying our distorted thoughts and beliefs, we can have better control over thoughts, thus better control over our feelings. Having distorted thoughts or beliefs doesn't mean that there is something wrong with us. We all have distorted thoughts and beliefs at different times in our lives. 

Some examples of distorted thoughts:



OVER-GENERALIZING: At times, we may see things as all-or-nothing. For example, if one thing goes wrong with a project, we may think that the entire project is a failure. Or, if there is one thing that upsets us about a person, we may decide we don't care for that person at all.



MIND READING: We assume that we know what someone is thinking. We may tell ourselves that someone thinks we are "stupid" or does not like us even though there is no evidence that supports this thought. This is called mind reading.



CATASTROPHIZING: We exaggerate how "awful" something is or imagine the worst possible outcome. Perhaps our boss wants to speak with us and we catastrophize that we are going to be fired. Or, it rains on one of the days of a vacation and we think "this is the worst thing that could have happened".



FORTUNE TELLING: We think we know for sure what is going to happen. For example, we tell ourselves, "I know I am not going to get that promotion" or "I won't be able to handle that assignment". 

In addition, specific behaviors or skills are taught including social skills, assertiveness, organizational skills, and relaxation techniques. These are taught during and between sessions. 

   

Below, are seven pearls that I will share with you that I have found helpful over the years in my practice:

  

1. DISCUSS GOALS OF TREATMENT

During the initial assessment phase, it is important to collaborate on the goals of treatment. This helps keep the treatment focused and productive. Without goals, therapy can end up focusing on whatever problem is coming up that week and can interfere with progress of the original presenting problems. Sometimes, the patient may not be able to specifically describe a goal except a vague "I want to be less anxious" or "I want to feel happier".  This is fine at the beginning. However, over the first couple of months, you should return to this discussion about goals to see if they can be described in more specific terms. 

For example, if someone presents with depression, the goals may include the following: Finding a more fulfilling job, returning to college, exercising three times a week, making two new friends, and stopping the use of marijuana.

2. START EACH SESSION WITH AN AGENDA

Every session should start with an agenda that is discussed collaboratively between the therapist and the patient. Again, this helps to keep the session focused and more effective. The agenda should include following up on homework from the previous session, a check-in about the mood and week, bridging or reviewing the topics and progress from the previous session, and topics related to discuss in the current session that is related to a specific goal.

3. DISCUSS WHERE TO ADDRESS THE ISSUE

Most therapy goals will have several components including distorted thoughts, beliefs or behaviors. Thus, during the session, collaboratively decide on which level to address the goals. If you are working on distorted thoughts, it is important to elicit what thoughts or images occur that are leading to the distress, such as anxiety, low mood, or blocking a certain behavior. If you are working on certain behaviors such as social skills or relationship issues, it is important to discuss when the skills will be used and how likely it is the skills will be used. Another useful technique for addressing behaviors is role playing and visualizing which helps to practice the skills and address any blocks or anxieties around the behavior.

4. USE FLASHCARDS

Flashcards can be used to remember the key points of the session or a mantra that may help with certain thoughts or feelings. If I am working with a patient who is struggling with depression, I will title the flashcard something like "Survival Kit" and it will include strategies to cope with the depression such as reaching out to a friend, getting out of the house, reaching out to me, or taking care of a small chore.

5. STAY FOCUSED

At the beginning of treatment, goals for therapy are discussed. Sometimes, the therapy session may head in a direction that is unrelated to any of the goals of treatment. This is appropriate at certain times, but if this is happening every session and for the entire duration, then there can be a limit to the progress of therapy. Structure is important in CBT, but flexibility is also important. This would be a time to collaborate to discuss whether to continue on the current diversion or issue that is being discussed or go back to what was discussed in the agenda.

6. ASSIGN HOMEWORK

Towards the end of each session, a collaborative discussion takes place about homework or "action tasks" to perform between sessions. An action task might be to buy a calendar if one of the issues is time management or recording thoughts and images that occur during stressful periods in a notebook to discuss and address at the following session. Always make sure to follow-up on the homework or action task at the next session or it creates the impression that working on problems or goals in between sessions is not a crucial part of getting better.

7. ASK FOR FEEDBACK

Towards the end of the session, ask what went well during the session, what could have gone better, and what the main take-away messages are. This helps to build the alliance, improve future sessions, and maximize progress.

Cognitive behavioral therapy is an extremely effective form of therapy, either with or without medications and is an excellent way to practice psychiatry.

 

If I can be of help or you have any questions about cognitive behavioral therapy, adult ADHD or medications, please feel free to email me at scott@scottshapiromd.com or call 212-631-8010.

Scott

Scott Shapiro, MD, FAPA

First FDA Approved Scan for ADHD--7 Things to Know about ADHD and Brain Scans

The FDA recently approved the first mental health diagnosis to use a brain scan called an electroencephalogram, or EEG, that measures electrical impulses in the brain.  The EEG records different brain wave patterns including alpha, beta, delta, and theta waves.

In children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD), the ratio of theta to beta waves has been shown to be higher. The FDA approved test is called the NEBA, the Neuropsychiatric EEG-Based Assessment Aid System.

The study used to receive FDA approval included 275 children and adolescents. The study concluded that NEBA can assist in the diagnosis of ADHD amongst children and adolescents.

Here are 7 Things to Know about NEBA:

1.    The test takes 20 minutes to complete.

2.    As with all tests results such as labs and x-rays, the information should be used with other clinical assessments such as a psychiatric evaluations and questionnaires.

3.    This test has only been approved in people aged 6-17 years old.

4.    It has NOT been approved for adults but may eventually prove beneficial.

5.    In the future, more sophisticated scans such as the functional MRI (fMRI) may aid in the diagnosis of ADHD. 

6.    Eventually, the NEBA may assist in other mental health assessments such as depression, bipolar disorder, and autism.

7.    In my opinion, further research is necessary prior to recommending the NEBA due to the limited size of the study.

The NEBA is the first FDA-approved scan to assist in a psychiatric diagnosis and eventually may be used for other disorders. In addition, it could lead to further research in using more sophisticated scans in the diagnostic process. At this time, I feel further research is necessary before using this tool clinically.

Resources:

Goldberg, Dan. Brain wave scan, approved by FDA, could help detect ADHD. Star-Ledger On-Line. July 17, 2013.

Park, Alice. Reading the Brain: FDA Approves First Scan for Diagnosing ADHD. Time Magazine On-Line. July 16^th, 2013.

5 Easy Steps for Diagnosing Adult ADHD

5 Easy Steps for Diagnosing Adult ADHD

The proper diagnosis of Adult ADHD can be confusing and overwhelming; many of the symptoms overlap with other disorders and many of the symptoms are set along a wide spectrum. Additionally, most clinicians have not been extensively trained in the accurate diagnosis of Adult ADHD.

This is a brief and simple step-by-step guide to the diagnosis of Adult ADHD so that you can feel more confident in assigning the diagnosis and referring to a therapist and/or psychiatrist who specializes in the comprehensive treatment of Adult ADHD.

 Step 1: Ask these key screening questions:

1.  Do you have difficulty reading magazines, books, or maps?
2.   Do you have a messy office or home?
3.   Do you have trouble starting and/or completing projects?
4.   Do you often feel mentally “foggy” or “in a haze”?
5.   Do others say you tend to jump from topic to topic in conversation?
6.   Have you received negative feedback, such as inconsistent performance, in your school or work reviews?
7.   Have you had any or all of these problems since childhood?
8.   Which family members, if any, have depression, anxiety, mood swings, or problems with attention and focus?

Step 2: Administer the ADHD Screening Exams called the ASRS v1.1 and the Epsworth inventory on all patients.

Step 3: Gather collaborative information:

Many young adults may try to receive a diagnosis of ADHD in order to get stimulant medications even when they do not have ADHD, so it is critical to review collaborative information whenever practical. 
Assess past report cards and performance reviews for clues pointing toward ADHD.
Always speak to family members, whenever possible.

 Step 4: Administer the Conners Test

This is the gold standard for inventories and is, in fact, superior to neuropsychiatric testing. The diagnosis of ADHD is a clinical diagnosis and does not require neuropsychiatric testing unless you are also evaluating for learning disabilities. 

Step 5: Rule out medical or psychiatric disorders that can mimic or coexist with Adult ADHD:

There are many medical and psychiatric disorders that can mimic the symptoms of Adult ADHD. These are a few conditions that may exhibit similar symptoms:
1.   Chemotherapy
2.   Menopause
3.   Sleep apnea
4.   Insomnia
5.   Bipolar Disorder, depression or substance abuse
6.   Medications such as blood pressure medications and antibiotics
7.   Multiple Sclerosis, seizures, HIV, head injuries

How do you distinguish these scenarios from Adult ADHD?  After taking a detailed history, determine whether the symptoms began after early adolescence. If so, it is NOT ADHD. If the symptoms fluctuate, it is NOT ADHD.

It should be noted that in certain situations, such as menopause, depression, or chemotherapy, stimulants are commonly used and are effective for the treatment of poor focus and attention, distractibility, and low motivation. 


Following these simple steps, you as a clinician can more effectively diagnosis and refer your patients who most likely have Adult ADHD or present with similar symptoms. It is important that this provider has had specialized training in the diagnosis and treatment of Adult ADHD.