Pressed

Effective
Psychological
Interventions
In Primary Care
Editor: Dr Andrew Peh
Contributors:
Dr Andrew Peh
Ms Janet Chang
Dr Jean Cheng
Ms Lim Hui Khim
Ms Pan Huimin
Dr Tan Wee Chong
Dr Tan Wee Hong
Ms Yang Chek Salikin
All rights reserved. No part of this book may be translated, reprinted,
reproduced, transmitted or utilised in any form or by any electronic,
mechanical or other means, whether now known or invented in
future, including photocopying, recording, or by any other information
processing, storage or retrieval system, in whole or in part, without prior
written permission from the publisher, Eastern Health Alliance Pte Ltd.
Medical knowledge changes constantly. As new medical research and

clinical experience deepen our knowledge, changes in treatment may be
needed. The authors and publisher have used their best endeavours to
provide information in this book which they believe to be correct at the
time of publication. However, in view of the possibility of human error by
the authors or publisher in its contents or changes in medical knowledge,
neither the authors or publisher or any other party involved in preparing
this book warrants that the information in it is accurate or complete, and
are not responsible for any errors, omissions or for any results obtained
or consequences whatsoever arising directly or indirectly from the use
of such information. This book is intended to be a general guide and
cannot be a substitute for professional advice. Readers are advised to
refer to the body of literature on the subject for accuracy, adequacy,
timeliness, or completeness of any information in this book and to seek
such professional advice when needed.
Copyright © 2016 by Eastern Health Alliance (EHA)

Published by Eastern Health Alliance

Inquiries and correspondence should be addressed to:
5 Tampines Central 1
Tampines Plaza #08-01/05
Singapore 529541
ISBN 978-981-09-6566-2
Printed in Singapore
AuthorBiography
Dr Andrew Peh
[MBBS, M.Med (Psych), FAMS]
Psychiatrist, Changi General Hospital
Dr Peh is a Senior Consultant in the

Department of Psychological Medicine,
Changi General Hospital, where he is
in charge of the addiction medicine programme. He is
also the joint Programme Director of Health Wellness
Programme at Eastern Community Health Centre. Dr Peh
is Adjunct Assistant Professor in Duke-NUS Graduate
Medical School, Senior Clinical Lecturer in the YLL-NUS
School of Medicine, Clinical Core Faculty in the National
Psychiatry Residency, as well as Physician Faculty for the
SingHealth Family Medicine Residency.
Ms Janet Chang
[MPsych (Clin) (Melb); B.SocSci (Hons) (NUS)]
Clinical Psychologist, Changi General Hospital
Ms Chang is a clinical psychologist

at Changi General Hospital. She also
provides group and individual therapy at
the Eastern Community Health Centre under the Health
Wellness Programme. Ms Chang obtained her Master
of Psychology (Clinical) at the University of Melbourne.
She has worked in both clinical and community settings,
providing therapy and assessments for people with a
range of mental health issues such as depression, anxiety,
adjustment issues, insomnia, and schizophrenia. Originally
trained in Cognitive Behavioural Therapy, Ms Chang has
also developed an interest in Positive Psychology and
Acceptance and Commitment Therapy approaches.
Dr Jean Cheng
[PhD, MPsych (Clinical), B Arts (Hons)]
Clinical Psychologist, Changi General Hospital
Dr Cheng completed her Masters in

Clinical Psychology and PhD investigating
the relationship between emotion dysregulation
and impulsivity in borderline personality disorder self-harm
behaviour at the University of Melbourne. She has clinical
and research experience in adolescent and adult public mental
health services in Singapore and Australia. Her clinical work
encompasses inpatient and outpatient settings where she
delivers psychological assessment as well as individual and
group therapy for individuals with psychological disorders, such
as anxiety, depression, eating disorders, and personality issues.
Ms Pan Huimin
[B.Sci.Occ Therapy (La Trobe)]
Senior Occupational Therapist, Changi General Hospital
Ms Pan is a Senior Occupational Therapist

working at Changi General Hospital. She
graduated from La Trobe University with a
Bachelor of Science in Occupational Therapy, and
has many years of experience working with acute physical
dysfunction and mental health. She has a special interest in using
hydrotherapy for relaxation and expressive arts for her patients.
She currently provides mental health occupational therapy services
at CGH and conducts expressive arts therapy at the Eastern
Community Health Centre. She also treats patients who have
difficulty coping with the psychological effects of chronic medical
illness and disability.
AuthorBiography
Ms Lim Hui Khim
[M.Soc.Sc (Psychotherapy & Counselling), CCS,
CSAC, CGAC]
Senior Mental Health Counsellor,
Eastern Health Alliance
Ms Lim is a Senior Mental Health

Counsellor with Eastern Health
Community Health Centre. She has over 13 years of
experience working in the mental health and addiction
setting. She is actively involved in the supervision
work, programme development, counselling and
support for individuals, couples and families facing
both mental health and addiction issues. She uses a
combination of therapy approaches in her practice,
applying them to both individual and group therapy.
Dr Tan Wee Chong

[D.Psych, B.SocSci (Hons)]
Senior Clinical Psychologist, Changi General Hospital
Dr Tan is an Australian-registered clinical

psychologist who holds a professional
doctorate in clinical psychology. He has worked
extensively in the mental health, forensic and healthcare
field in Singapore and Sydney. He has provided psychological
assessment and psychotherapy for persons with various
mental illnesses, persons with dementia as well as for
persons suffering from health-related issues e.g. chronic
pain, sleep, HIV, and Irritable Bowel Syndrome. Dr Tan is
also experienced in developing community mental health
programmes. He has a special interest in Person-Centred
and Experiential Psychotherapy.
Dr Tan Wee Hong
[D.Psych, B.SocSci (Hons)]
Senior Clinical Psychologist, Changi General Hospital
Dr Tan is an Australian-registered clinical

psychologist who holds a professional
doctorate in clinical psychology. He has worked
extensively in the mental health and healthcare field in Singapore
and Australia for about 10 years. He has provided psychological
assessment and psychotherapy for persons with mental illnesses
spanning from anxiety disorders to personality disorders, as
well as for persons suffering from health issues e.g. chronic
pain, sleep, cardiac problems, diabetes, and renal failure. Dr
Tan is also experienced in developing community mental health
programmes.
Ms Yang Chek Salikin

[Master of Nursing (Mental Health) (NUS)]
Advanced Practice Nurse, Changi General Hospital
Yang Chek has been in the nursing

profession for the past forty years. She was
from the pioneer batch of graduates with the
Master of Nursing Degree conferred by the National University
of Singapore in 2006. Besides being registered as an Advanced
Practice Nurse in Mental Health, she was also a certified
substance abuse and gambling counsellor. She has many years
of experience in psychiatric nursing in various areas, including
subspecialties such as forensic psychiatry and addiction
medicine. She also provides training for nurses, doctors, other
health care professionals and community volunteers.
Foreword
“C ongratulations to Dr Peh and his team of trainers for getting into
print, this handy book on effective psychological interventions.
The authors have decided to focus on intervention strategies as
the primary thrust of this book. The knowledge and application of skills
in the preceding steps of case assessment and formulation in the reader
is assumed.
The intended readership of this book is primary healthcare providers and

this book will be of use to many – family doctors, nurses, and allied health
professionals. The latter will include psychologists, physiotherapists,
occupational therapists, speech therapists, and dieticians.
I am told that this book will be a companion information resource to the

skills training modules on psychological interventions that Dr Peh and his
team will be conducting in the coming year for primary care professionals.
Nothing beats having a book to refer to catch up on details after the day’s
training is over.
In this book is the survival guide on techniques to promote behaviour

change, cognitive change, mindfulness, relaxation, and very importantly,
good sleep."
Associate Professor GOH Lee Gan

[BBM, MBBS (Singapore), MMED (Internal Medicine), FCFP(Singapore),
FRCGP, FRACGP, Fellow Wonca ]
Professorial Fellow, Division of Family Medicine, Department of Medicine,
National University Health System, Singapore
8 October 2015
A/Prof Goh passionately believes that family doctors should develop to

the best of their capability, and over the last two decades has contributed
actively to the development of Family Medicine in Singapore. He is co-
author of the book “Counselling Within the Consultation: Brief Integrative
Personal Therapy”.
Acknowledgements
W e are grateful to A/Prof Goh Lee Gan, for writing the foreword.
Prof Goh has been a strong advocate for community mental
health for many years.
We also wish to express our sincere thanks to Mr T K Udairam, Group

CEO of Eastern Health Alliance (EHA), Dr Wee Moi Kim, Deputy Director,
Community and Mental Health, EHA, and Dr Derek Tse, Director,
SingHealth Polyclinics, for their strong support.
Special thanks go to Mr Ian Shen, Executive, and Ms Karen Kan, Senior

Manager, EHA, for the layout and administrative assistance in the
production of this book. Thanks also to Dr Tan Wee Chong and Dr Tan
Wee Hong for the graphics used in this book, as well as to Dr Andrew Peh
for use of the photographs of his paintings. We also wish to thank Dr Wee
Moi Kim and Ms Lina Farhana Binte Rosle for their help in proofreading.
The description of the psychological interventions in this book has

been adapted from various clinical handbooks. In particular, we wish to
acknowledge the contributions from the following:
• David Mee-Lee, M.D. (2005). Motivational Interviewing: Helping People Change.

The Change Company.
• Centre for Substance Abuse Treatment. (1999). Enhancing Motivation for Change
in Substance Abuse Treatment. Substance Abuse and Mental Health Services
Administration (US). Rockville (MD).
• Westbrook, D., Kennerley, H., & Kirk, J. (2011). An Introduction to Cognitive
Behavioural Therapy: Skills and Applications (2nd Ed.). London: Sage Publications.
• Davis, M., M’Kay, M., Eshelman. E.R. (2010). The Relaxation and Stress Reduction
Workbook. 6th ed. US: New Harbinger Inc.
• Perlis, M., Aloia, M., Kuhn, B. (2011). Behavioural Treatment for Sleep Disorders:
A Comprehensive Primer of Behavioral Sleep Medicine Interventions. London:
Elsevier.
Contents
Author Biography .................................................................................................... ii
Foreword .................................................................................................................. vii
Acknowledgements ................................................................................................ viii
Introduction
Making Every Consultation a Therapeutic Encounter .................................... 1
Chapter 1
Supportive Therapy ................................................................................................ 9
Chapter 2
Psychoeducation ..................................................................................................... 29
Chapter 3
Motivational Interviewing ..................................................................................... 41
Chapter 4
Cognitive Behavioural Therapy ........................................................................... 75
Chapter 5
Mindfulness and Self-compassion ....................................................................... 111
Chapter 6
Relaxation Techniques ........................................................................................... 139
Chapter 7
Behavioural Strategies for Insomnia.................................................................... 161
References ................................................................................................................ 185
About the Health Wellness Programme ............................................................ 196

xiv
1
Introduction
Making Every Consultation

a Therapeutic Encounter
2 Introduction
“ What we achieve
inwardly will change
outer reality."
Plutarch
M
ental healthcare should be accessible, affordable and
timely. For adjustment disorders, mild to moderate anxiety
and depression, the right siting for treatment is in primary
care. Recognising this, much effort have been made in recent years
to train primary healthcare providers – family doctors, nurses, and
allied health – to have the capability to deliver mental healthcare
to their patients within the community.
Is prescribing patients just medication adequate?

Evidence-based treatment for mild emotional and psychological
conditions is psychotherapy, not medication. For moderate to severely
ill patients, they often respond better to a combination of medication
and psychotherapy.
We know that even with placebos the patients do recover. The so-
called placebo effect is not inert, as commonly believed. It is an active
ingredient in the clinical consultation – whether medical, surgical or
Making Every Consultation a Therapeutic Encounter 3
psychological – which has a positive effect on health. It is believed

that the placebo effect arises from the psychotherapeutic factors
that occur during any clinical session.
What has trust got to do with it?

At the heart of medical professionalism is trust, which is the main
ingredient for a good doctor-patient relationship. Trust denotes the
cognitive and emotional aspects of a patient towards the doctor;
what a patient thinks about the doctor and how the patient feels
toward the doctor – these determine the extent of trust a patient has
for his or her doctor. If we wish to attain the best treatment outcome,
we should try to promote a positive psychotherapeutic experience
for the patient in every consultation.
Cognition T R U ST
Thoughts about the
doctor
Emotions
Feelings towards the
doctor
4 Introduction
How then does a doctor gain trust from a patient?

According to Dr Shaun Shea in his book “Psychiatric Interviewing:
The Art of Understanding“, the doctor needs to engage the patient.
This process refers to the ongoing development of a sense of
safety and respect, from which the patient feels increasingly free
to share his or her problems, while gaining an increased confidence
in the doctor's potential to understand him or her. This requires
empathy, which is the ability to accurately recognise the immediate
emotional perspective of another person while maintaining one’s
own perspective. Some doctors are naturally empathetic; for those
who are not so, it is a skill that can be learnt.
If the doctor is able to convey a warm attitude and sense of caring,

compassion, kindness and genuineness, the patient will readily grow
to trust that doctor. These are the so-called major generic skills which
form two of Dr Carl Rogers' core conditions: empathic understanding
and unconditional positive regard toward the patient.
MAJOR GENERIC SKILLS

that form Dr Carl Rogers’ proposed two core conditions for person-
centered therapy: (1) empathic understanding & (2) unconditional
positive regard toward the patient
GENUINE-
CARING COMPASSION
NESS
WARM
KINDNESS ATTITUDE
Does a patient with a psychological or emotional

condition require specialised treatment with
psychotherapy to get better?
In the book “Every Day Gets a Little Closer: A Twice-told Therapy”, Dr

Irvin Yalom, a prominent psychotherapist, and his patient agreed to
write separate journals of each of their sessions in which they relate
their descriptions and feelings about their therapeutic relationship.
On the day that the therapist thought he had carried out a brilliant
technique, the patient’s description of the session simply dwelt on
one seemingly insignificant act by the therapist!
It is said that of the total improvement a patient makes, only one-

third can be attributed solely to techniques, another one-third to the
therapeutic relationship, and the last one-third to extra-therapeutic
factors. Dr Scott Miller is a renowned clinical psychologist who
has studied the area of using measures to predict outcomes of
psychotherapy sessions. In his book “The Heart and Soul of Change:
Delivering What Works in Therapy”, he examined the common
factors underlying effective psychotherapy and brought the client-
therapist relationship back
into focus as one of the key
determinants of psychotherapy
outcome. Family doctors can Therapeutic Techniques
also increase their therapeutic Relationship
effectiveness substantially
by paying attention to the Extra-
therapeutic relationship. Therapeutic
Factors
TOTAL
TOTAL IMPROVEMENT
IMPROVEMENT
OF PATIENT
OF PATIENT
6 Introduction
So while techniques are helpful, a family doctor does not need

specialised training in psychotherapy to be able to achieve best
outcomes. It is more important to hone basic skills such as active
listening and expressing empathy, and use them effectively to
establish a good therapeutic relationship.
Where can a family doctor obtain training in

psychological interventions?
Counselling services may be readily available, but some patients may

not be keen to be referred to such services. Therefore one of the
competencies a family doctor may wish to achieve is that of carrying
out brief but effective psychological interventions with their patients.
This book offers information about such brief interventions, which
are evidence-based treatments suitable in primary care.
Skills training may be arranged with the authors, who are clinical staff
of the Health Wellness Programme (HWP) under Eastern Health
Alliance (EHA). HWP provides support for patients who are being
treated for emotional and psychological conditions by their family
doctors within the community.
8
Chapter 1
Supportive Therapy
Key Points At A Glance
9
10 Chapter 1
“ The most precious gift

we can offer others is
our presence."
Thich Nhat Hanh
D
r Long had just about completed examining his
20-year-old patient, Darren. He had seen Darren
since the patient was a young boy and knew him to be
very healthy and fit. Hence, he was more than a bit puzzled
as Darren had fallen ill very frequently over the past two
months, complaining of symptoms of flu and fever. Dr Long
decided to explore this with Darren. Unexpectedly, Darren
started to tear, saying that he was feeling very stressed. This
chapter will illustrate how Dr Long used a simple therapy
framework to explore the issues and provide support to Darren.
Why Should Busy Family Doctors Provide

Supportive Therapy?
Because of their already heavy workload, it is understandable that
family doctors would baulk at having to provide supportive therapy
for their patients. They may be concerned that this would take
up too much of the limited consultation time. Another reason is
that many family doctors do not feel adequately trained to provide
supportive therapy.
Supportive Therapy 11
Research has demonstrated that patients’ medical outcomes

benefit from their family doctor's application of supportive therapy
during the medical consultation. For instance, Kim, Kaplowitz and
Johnston (2004) have found that patients who received empathic
communication from their doctors reported greater satisfaction and
were more adherent to medical treatment. Indeed, a study conducted
by Hojat and colleagues (2011) found that diabetic patients who had
highly empathic doctors were more likely to have good control over
their Hemoglobin A1c and LDL-C than those who had doctors with
little empathy.
More recently, Pollak and colleagues (2011) repeated these findings,

adding that patients also perceived that their sense of autonomy was
supported by their doctors where treatment decisions have to be
made. This sense of autonomy is one reason why patients are more
adherent to treatment when they receive empathic understanding
from their doctor. Another reason why supportive therapy could
benefit patients’ medical outcomes is that many patient visits are
due to psychosocial issues. The psychosocial stressors and their
resultant impact on lifestyle would affect the physical illnesses. It
is hence important to address these psychosocial issues as part of
comprehensive medical treatment.
12 Chapter 1
What Is Supportive Therapy?

Supportive therapy can be considered a time-limited process of
building upon the therapeutic relationship (in this case, the doctor-
patient relationship) to provide the patient with a sense of being
supported emotionally. It is also the foundation upon which the other
brief interventions discussed in this book are applied – the doctor
almost always needs to start building up a therapeutic relationship
before offering other interventions.
Supportive therapy comprises two elements:

• A directed dialogue (made up of a loose sequence of steps)
• Use of some important interactional skills
This can be incorporated into the regular medical clerking. It is

usually brief and can be conducted within the span of a regular
medical consultation. Central to this whole process is the concept
A
TIP
EMPATHY - HOW TO WALK IN THE PATIENT’S SHOES
To the best of his or her ability, the doctor tries to experience what
the patient is feeling. This experiencing of the patient’s feelings can
be achieved by considering a combination of several factors:
• Some prior knowledge about the patient as a person (i.e.
personality and background)
• Observing the patient’s verbal and non-verbal responses
• Imagining oneself in the patient’s shoes
• Recalling experiences that one has had that are similar to the
patient’s experience.
For instance, should a patient have been just diagnosed to have a

chronic illness, how would he or she feel upon receiving this news?
In order to arrive at a rough sense of the patient’s feeling, the doctor
can consider the following:
• What is the patient’s background and personality like?

• What is the patient saying and doing right in front of the
physician?
• Imagine what it would feel like to receive such a diagnosis.
• Recall a similar experience of receiving bad or momentous news.
and practice of physician empathy. Put in another way, empathy

refers to the doctor feeling with the patient, not merely feeling
for the patient. The directed dialogue and the interactional skills
are used to increase physician understanding and empathy, and to
demonstrate that empathy to the patient.
A Simple Framework for Supportive Therapy

The framework is encapsulated by the acronym AUS – Assess,
Understand and Suggest.
It should be noted that the three steps (AUS) are not necessarily
conducted in a linear sequence (e.g. A  U  S). Rather, the
dialogue can move and be repeated between any of these steps
in any order. Oftentimes, it might cycle between the A and U
steps before moving to the S step. The doctor needs only five to
10 minutes if they follow this framework. Within the Assess and
Understand steps, there are some simple interactional skills that the
doctor could use to drive the dialogue.
ASSESS, UNDERSTAND AND SUGGEST FRAMEWORK
Assess to
understand
central concerns
needs/goals/wishes
understand &
Suggest Express Empathy
options of the patient’s situation
& feelings
14 Chapter 1
What are some of these interactional skills?

By using various interactional skills, the doctor finds out more about
the patient’s concerns and demonstrates his or her empathy for the
patient. It would then be easier for the doctor to suggest options
for the patient. Here is an overview of the interactional skills, with
standard examples for these skills:
ASSESS, UNDERSTAND AND SUGGEST FRAMEWORK
Assess to Understand
1. “What is bothering you?”
2. “What troubles you the most about it?”
3. “How do you feel about it?”
4. “How are you handling this?”
5. “What do you need? What would
help you to feel better?”
SUGGEST Options understand & Express

1. Provide information Empathy
2. Medical intervention By saying back patient’s feelings:
3. Offer other brief psycho- 1. “You feel _____ (sad/mad/glad/
therapeutic interventions scared).”
2. “That must be very hard for you.”
3. “No wonder you feel stressed.”
Using encouraging behaviours -
1. “Uh-huh”, Nodding, Eye contact
1. Asking questions
This is easier for doctors to do as it is not very far removed from
the usual diagnostic interview. However, the questions need to
be asked in an open-ended fashion. These are questions to which
the patient would answer with more information and details, as
opposed to a straightforward “yes” or “no”.
Examples of open-ended questions include:

“What happened?”
“When did it happen?”
“Where were you at that point?”
l
“How did you feel then?”
“Which aspect of the incident most affected you?”
“Why was that so?”
The following question formats are useful:

• The doctor could open the conversation by asking: “What is
bothering you?”
• Once the patient describes their concern, the doctor can focus
in on the central part of the concern by asking: “What troubles
you the most about it?”
• Once the central concern is identified, the doctor could explore
the patient’s feelings by asking: “How do you feel about it?”
This provides material from which the doctor could express their
understanding and empathy.
• The doctor could also get an idea about what would help the
patient by asking either: “What do you need?” or more specifically
“What would help you feel better?”
• As part of the assessment, the doctor could also ask about the
patient’s coping by asking: “How are you handling this?”
16 Chapter 1
2. Reflecting Feelings
This is a more difficult interactional skill to apply. There are a few
reasons why reflection of feelings could pose some challenges for
doctors (and most people). They might be uncomfortable with
addressing emotions, and there might be the concern that identifying
with patients emotionally could affect and overwhelm the doctor's
own emotions. Within
Asian cultures, there is an
added level of reservation A
TIP
REFLECTING FEELINGS 1
about exploring emotions.
Think back to a time when you had a very
Nonetheless, as with any engrossing conversation. If you were
medical procedure, the doing the talking, what did the other
doctor will become more person do to make the conversation
so engrossing? If you were the one
comfortable and confident listening, how did you listen to make the
with reflecting feelings conversation so engrossing?
after some practice. Think of the mannerisms of a good
listener.
Reflection of feelings involves the doctor saying back what he or she

has heard the patient say, or imply, about feelings. It focuses on the
patient’s feelings, as opposed to facts. The doctor, in the act of saying
back to the patient what he or she believes the patient is experiencing,
is demonstrating empathy. It
requires the doctor to put
him or herself briefly and
quickly in the patient’s shoes,
A
TIP
REFLECTING FEELINGS 2
get a sense of the patient’s You don’t have to get the feeling
accurate. All you have to do is to
feelings, and then saying this demonstrate to the patient that you
back to the patient. are making the effort to understand
them.
The whole process is summarised as follows:

Doctor listens to the patient

Doctor puts him or herself in the patient’s shoes to
understand the patient’s feelings

Doctor reflects the patient’s feelings
The following format can be used when reflecting the patient’s

feelings:
• When the patient describes their feeling, the doctor can
reflect that by saying: “You feel .”
• Alternatively, the doctor can say: “No wonder you’re feeling
.”
Here is an example:
Patient (in an agitated high-pitched voice): “I’m super stressed
out! I’ve got so many things to do at work, and now my mom
wants me to help her book this holiday in Bhutan by tonight!”
Doctor: “You feel super stressed out. It’s all so overwhelming.

You’re also upset with your mom.”
Patient: “Yeah!”
Doctor: “You’ve got so many things to do, no wonder you’re
feeling this stressed.”
18 Chapter 1
There are times when the

doctor gets overwhelmed
A
TIP
READING PATIENT’S FEELINGS
by the patient’s story or
You can sometimes guess how the
concerns and may not know patient is feeling by looking at their
how best to respond. expression, posture and behaviour.
For instance, anxiety can come across
In this case, he or she can as frowning, agitated movement of
simply be attentive to the the hands, restlessness and fidgeting
in the seat, and sighing.
patient, in the following
manner: Think back to how you behave when
you feel sad, mad, scared or glad.
• Put aside the case notes or
keyboard
• Sit facing the patient and lean slightly forward
• Maintain eye contact with the patient
• Nod or use other encouraging sounds (e.g. “uh-huh”, “yeah”, “I see”,
“ok” or “yes”)
Here is an example:
Patient (in an agitated high-pitched voice): “I’m super stressed out!
I’ve got so many things to do at work, and now my mom wants me
to help her book this holiday in Bhutan by tonight!”
Doctor: (Faces the patient squarely, looking into her eyes, leaning
forward slightly)
Patient: “Do you have any idea how overwhelmed I am right now?”
Doctor (nodding her head): “Uh-huh.”
This approach is a useful fallback if the doctor is struggling to apply
reflection of feelings.
A
TIP
THE BASIC EMOTIONS
There are generally a few broad types of emotions:
• Sad – including any degree of low mood, unhappiness

• Mad – including all degrees of anger
• Glad – including happiness, elation, relief
• Scared – including all degrees of fear, terror, worry, anxiety
Think to yourself: If I were in this situation, what is the main
emotion I would feel?
If the doctor is unsure of the exact emotion to reflection, generic

terms “stressed” or “upset” can be instead. Another broad term
is “confused”.
E.g. “You’re feeling stressed and upset because of these
problems.”
To summarise, the doctor can combine various ways to get a sense

of what the patient is feeling, including observation of patient's
behaviour, imagining himself or herself in the patient’s situation, and
listening to how the patient describes the feelings (see the Tips
above). To say back the patient’s feelings, the doctor can follow
a standard response format (see above) or simply nod or make
encouraging sounds to show attentive interest.
Note: The dialogue might sometimes move back and forth between
the Assess step and the Understand step several times.
20 Chapter 1
A
TIP
THE BASIC EMOTIONS
It helps for the doctor to briefly calm his or her mind before
engaging in the conversation. A doctor, who is preoccupied with
the list of waiting patients and the paperwork, could hardly pay
attention to the patient.
Here is a method to briefly calm your mind before starting the

dialogue:
1. Breathe in comfortably and deeply through your nose,
letting your abdomen rise
2. Breathe out fully and slowly through your mouth, imagining
that you are breathing out the concerns, stress and worries
you have for the moment
3. Repeat the first two steps five to 10 times
3. Offering options
This is typically the final step, after the doctor has understood the
patient’s concerns and demonstrated empathy by reflecting the
patient’s feelings. When the patient feels heard and sometimes a
sense of relief at having verbalised concerns, he or she might be
more able to accept the doctor's suggestions.
Some of these options or suggestions are:

1. Giving information or advice
2. Performing psychoeducation
3. Listing various choices and weighing the options with the
patient
4. Providing further medical treatment if necessary
5. Carrying out some other brief psychotherapeutic
interventions described in this book
At this point, the doctor could also provide encouragement and give
feedback to the patient. Reinforce his or her personal strengths and
sense of self-efficacy (“You’ve done great to be coping so far” or “I’m
really impressed with how you’ve managed to cope so far”) wherever
possible. At the same time, the point of self-responsibility needs to
be emphasised to the patient if lifestyle changes are required.
What the doctor does in this step is based on the understanding
obtained from the other two steps.
Dr Long's session with Darren:

Dr Long decided to spend a few minutes finding out about
Darren’s stress: “What’s bothering you, Darren?”
Darren revealed that he was struggling with his school work

and he had a quarrel with his girlfriend recently. His mother
was also recently diagnosed with liver cancer.
Dr Long: “How do you feel about all of these problems?”
Darren almost spat out these words, “So many things to
handle all at one time make me depressed. Scared! I don’t
know!” He clasped his head in his hands.
“I see you’re feeling sad and scared. No wonder you’re so
stressed.” Dr Long, putting himself in Darren’s situation,
could readily understand these feelings.
Dr Long: “Of these problems, what troubles you the most?”
ASSESS UNDERSTAND SUGGEST

22 Chapter 1
Dr Long's session with Darren (Continued):

Darren mumbled, “I guess it’s my mom’s cancer. That’s
what I’m scared about.” He looked up at Dr Long.
Dr Long: “Yeah, that’s a scary thing, to learn that your
mom has cancer.”
Darren nodded vigorously. He felt relieved that his fears
were acknowledged.
Dr Long: “Can I check with you, what would help you feel
better?”
Darren took some time to think about this. “Maybe, if I had
more information about my mom’s cancer. I’m really scared
that she might die.”
Dr Long: “Yes, you feel very scared that your mom
might die from the cancer. Maybe I can give you some
information about that…”
ASSESS UNDERSTAND SUGGEST
This dialogue would have taken no more than five minutes.

Nonetheless, it provided Darren with a sense that Dr Long cared
about him, beyond his flu symptoms. Notice also that Dr Long did
not need to apply the Assess and Understand steps many times
over. He just needed to apply these steps occasionally during the
entire session. By simply going through these two steps, Dr Long
discovered what was causing Darren’s stress. Dr Long had also
gathered sufficient information about the psychosocial factors to
provide additional help for Darren.
A
TIP
WHAT IF THE SESSION TAKES TOO LONG?
1.Before you start the dialogue, you can let the patient know that it
will be short.
E.g. “Let’s talk about this for a couple of minutes.”
2. If you are aware of time and needing to end, simply let the patient
know that you need to end the session.
E.g. “You’re going through a lot and it’s very stressful. Unfortunately,
I’ve got to stop our chat now because of we’ve run out of time. I
hope things improve for you soon.”
When Should Supportive Therapy Be Used?
In general, it is useful for most clinical encounters. Here are some

situations which would particularly benefit from supportive therapy:
• Obvious emotional distress – When the patient shows

emotional distress during the consultation. The doctor could
spend a few minutes simply using some of the interactional
skills to provide relief for the patient.
• Patient voices concerns – When the patient voices concerns,
whether it is about his or her medical treatment or about
psychosocial problems, the doctor could attempt to find
out more about those concerns, or simply provide empathic
understanding.
24 Chapter 1
• Before offering other psychotherapeutic interventions –

It is recommended that the doctor engages in some of the
interactional skills with the patient before introducing any of
the other psychotherapeutic interventions in this book. This
would help the doctor understand what the patient’s central
issue is and hence identify the most suitable psychotherapeutic
intervention. It also enables the patient to feel heard, making him
or her more open to considering the other psychotherapeutic
interventions offered.
When is Supportive Therapy Unsuitable or Inadequate?
The following are some conditions for which the doctor should not
use solely supportive therapy or may find it unsuitable:
• Severe and disruptive personality disorder – this refers to

patients with fixed patterns of emotional and interpersonal
problems that are pervasive i.e. affect many areas of their lives
such as work, family, and relationships. Supportive therapy
might open up a protracted dialogue with these patients, and
even escalate their emotional problems, especially if they are
also paranoid.
• Acute psychosis – this refers to patients who are experiencing
hallucinations or hold fixed false beliefs i.e. delusions.
Medications are needed to treat persons who suffer from
acute psychotic disorders. Supportive therapy can be provided
when the symptoms remit.
• Actively suicidal – Patients who are actively suicidal require

more intensive and immediate care. They will also take a lot
of time to manage, and are best treated by a multi-disciplinary
team. The doctor should instead arrange for such patients to
be seen at a hospital emergency department.
• Substance abuse – this refers to patients who currently have
a severe alcohol use disorder or are abusing illicit drugs. Their
lives are often severely affected by their substance abuse and
treatment may require intensive and multi-disciplinary team
management. Supportive therapy is inadequate as a sole
treatment modality for this problem.
• Victims of violence – the doctor might encounter patients
who are the victims of physical and/or emotional abuse. These
patients may suffer from post-traumatic stress disorder (PTSD),
which requires intensive therapy. Supportive therapy can be
used but would not be sufficient as an intervention for PTSD.
26 Chapter 1
Key Points at a Glance
1. Supportive therapy can be used during the patient-doctor

interaction to enhance the quality of care to patients. It
usually only takes up a few minutes of the consultation
time, or it could be incorporated into the medical clerking
process.
2. To apply supportive therapy, the doctor need only keep
the following key points in mind:
• Assess the patient's central concerns and needs.
• Understand and express empathy about his or her
concerns by reflecting the patient’s emotions.
• Suggest options for the patient.
28
Chapter 2
Psychoeducation
30 Chapter 2
“ Never give up on someone

with a mental illness. When
"I" is replaced by "We",
illness becomes wellness."
Shannon L. Alder
winkgo.com
J
osephine, a 35-year-old sales manager, reported
recurrent anxiety attacks for the past one year.
The frequency of attacks and symptoms caused
her distress and impaired her ability to work. After seeing
her family doctor at the polyclinic, Dr Tan, she was told
she had Panic Disorder and that the treatment included
medication as well as therapy. Dr Tan gave her some time
to ask him questions about her condition. Initially she was
anxious that this diagnosis meant that she was “crazy.” Her
anxiety diminished as Dr Tan was empathic and conveyed
the confidence that she would benefit from treatment.
What is Psychoeducation?
Psychoeducation is about giving information about a certain situation
or condition that causes psychological distress. Understanding the
condition gives the patient a sense of mastery over it, and is one way
to combat psychological stress. It also leads to active participation
in self-management and relapse prevention. Increased knowledge
Psychoeducation 31
about depression, for example, is associated with better prognosis

as well as reduction of the psychosocial burden for the family. It is
also effective in improving medication adherence.
The format of psychoeducation can be group-based or individually

implemented. Individual psychoeducation has the advantage of
being more focused. There usually is some structure so that it
stays on track and each psychoeducation session will cover specific
content. However some flexibility is useful, in order to answer
certain questions about the condition that may trouble the patient.
What Are The Benefits of Psychoeducation?

Even brief passive psychoeducation interventions, such as giving
the patient an educational leaflet or online material for his or her
condition, can reduce symptoms for depression and psychological
distress. It can be applied immediately and is useful as an initial
psychosocial intervention in primary care. There are many resources
on the internet which are freely available (see References).
Common psychoeducation topics about anxiety, depression and

adjustment disorders are:
- Nature of the illness
- Symptoms
- Aetiological factors
- Treatment
- Lifestyle changes
- Recognising early signs of
relapse
- Prognosis
32 Chapter 2
How Can Psychoeducation be Performed Effectively?
The following are some useful tips when carrying out psychoeducation,
adapted from the book by Silverman, Kurtz, and Draper (1998), on
“Skills for Communicating with Patients”:
Providing the correct amount and type of information

a 1. Ask for patient’s prior knowledge before giving
information and find out extent of patient’s wish for
information.
2. Give information in manageable chunks, check for
understanding and use patient’s response as a guide
on how to proceed.
3. Ask patient what other information would be helpful
e.g. aetiology, prognosis.
4. Give explanation at appropriate times: avoid giving
advice, information or reassurance prematurely.
Aiding accurate recall and understanding

4 1. Organise explanation: divide into discrete sections,
develop a logical sequence.
2. Use explicit categorisation or signposting e.g. “There
are three important things that I would like to discuss
first...”, “Now, shall we move on to...”.
3. Use repetition and summarising to reinforce
information.
4. Use concise, easily understood language; avoid
medical jargon.
Psychoeducation 33
5. Use visual methods of conveying information:

diagrams, models, written information and
instructions.
6. Check patient’s understanding of information given
(or plans made) e.g. by asking patient to restate in
own words; clarify when necessary.
Achieving a shared understanding: incorporating the

y patient’s perspective
1. Provide opportunities and encourage patient to
contribute: ask questions, seek clarification or
express doubts; respond appropriately.
2. Pick up verbal and non-verbal cues e.g. patient’s
need to contribute information or ask questions,
information overload, distress.
3. Elicit patient's beliefs, reactions and feelings
regarding information given, terms used;
acknowledge and address where necessary.
Explaining treatment
2 1. Elicit patient’s reactions and concerns about plans
and treatments including acceptability.
2. Take patient’s lifestyle, beliefs, cultural background
and abilities into consideration.
3. Encourage patient to be involved in implementing
plans, to take responsibility and be self-reliant.
4. Ask about patient's support systems and discuss
other support available.
34 Chapter 2
An example of a
PSYCHOEDUCATION SESSION
A
Using the above clinical scenario, Dr Tan proceeded to answer some of
the questions Josephine had pertaining to the diagnosis and treatment.
Dr Tan: "Well, based on what you described just now and based
on some of your responses on the questionnaire you
have completed, it seems that you are suffering from
Panic Disorder."
Josephine: [Looks worried] "What is it? Does it mean I’m going crazy?"
Dr Tan: "Don’t worry, you’re not going crazy. Panic Disorder is a

condition where anxiety becomes very strong. Often
people experience repeated panic attacks like those
you have described and because they are concerned
about these attacks, they may avoid certain places or
activities that might trigger these attacks."
Josephine: [Still looking worried] "What is causing this? I’ve been

alright all this time!"
Psychoeducation 35
Dr Tan: "Well Josephine, there are many possible causes of

Panic Disorder; usually several factors are involved,
such as abnormality in the serotonin chemical system
in the brain, genetic contributions and family history.
Panic Disorder can also be associated with major life
events or stress like those that you are experiencing
now. Does that help to answer your question?"
Josephine: "Yes, now I’m concerned about what can be done

about it. Will I get better? Is it long-term? "
Dr Tan: "Treatment often involves a combination of SSRIs

and CBT. Let me explain. SSRIs stands for Selective
Serotonin Reuptake Inhibitors and help to increase
the serotonin in your brain which reduces the
anxiety. In the meantime, I also advise patients to
go for Cognitive Behavioural Therapy or CBT with a
psychologist. This is a form of treatment that enables
you to learn better ways to change your anxiety-
related thought patterns and behaviours."
Josephine: "Sounds like a lot of commitment."
Dr Tan: "The SSRIs may take a few weeks to take effect

and typically, CBT runs for 10 to 12 sessions with
the psychologist. Together, these have very good
outcome for Panic Disorder."
Josephine: "Will I be cured?"
Dr Tan: "I think it’s more about controlling and managing your
anxiety. Because anxiety is part of our emotions, we
cannot get rid of it, but you can learn skills to keep
the anxiety from affecting your life."
36 Chapter 2
APPENDIX
Factsheets on Depression, Anxiety and Adjustment Disorder
KNOWING MORE ABOUT DEPRESSION

What is it?
Disorder that affects your mood where people can experience some
or all of the following for two weeks or more with persistent low
mood:
• Sleep difficulties • Poor concentration
• Loss in interest in usual • Change in appetite
things • Feeling that you are
• Guilt feelings moving slower than before
• Loss of energy • Thinking about suicide
• Anger • Social withdrawal
Why does it happen?

Different factors can contribute to having depression. Some of these are:
• Genetics
• Brain chemical changes
• Negative thinking patterns
• Loss and grief
• Sense of failure
• Loss of meaning in life
• Insufficient rewarding activities in life
• Loneliness and isolation
• Stressful life situations
What can be done?

Seeing a doctor for medication and psychotherapy can be very
helpful. Self-help tips include:
• Keeping a consistent daily • Talking and reconnecting

routine with other people
• Having more pleasurable • Taking self-care breaks at
and rewarding activities in work
your daily routine
Psychoeducation 37
APPENDIX
KNOWING MORE ABOUT ANXIETY

What is it?
Anxiety is a normal emotion that warns us about danger. It keeps us
safe. However if it becomes too strong or lasts too long, it will affect
our lives. Anxiety symptoms include:
• Shortness of breath • Poor concentration
• Racing heartbeat • Feeling tense
• A lot of worrying or • Always being on alert for
thinking about what can go danger
wrong
Why does it happen?

Different factors can contribute to having anxiety. Some of these are:
• Genetics
• Brain chemical changes
• Thinking patterns about how things may
go wrong or worrying about the future
• Avoiding things that triggers the anxiety
so that your body doesn’t get used to the
trigger
• Having overly high standards for yourself
• Stressful lifestyle
What can be done?

• Gradually exposing yourself • Practising mindfulness which
to the things that made you will help you to detach from
anxious so that you can get worrying
used to it
38 Chapter 2
APPENDIX
KNOWING MORE ABOUT ADJUSTMENT DISORDER

What is it?
We all experience changes in our lives. Sometimes big changes can
make us feel that we cannot cope with them and we may experience
some of the following symptoms:
• Mood changes (low mood, • Being irritable
mood swings) • Social withdrawal
• Anxiety • Reduced productivity at
• Sense that we cannot cope work
• Feeling burnt-out
Why does it happen?

Some of the following can overwhelm us and make us feel that we
cannot cope:
• Too many life changes occurring together
• Life changes that are too big
• Insufficient social support
• Perceiving changes as threats instead of
challenges
• Poor problem-solving skills
• Poor emotional management skills
• Unhealthy lifestyle
What can be done?

• Keeping a healthy lifestyle • Reaching out to others for
• Making a list of things that help
you need to do and solve the • Learning self-soothing
easier ones first strategies to help manage
• Breaking down big tasks into your mood better
smaller and more
manageable tasks
Psychoeducation 39
Chapter 3
Motivational Interviewing
42 Chapter 3
“ Being happy doesn't mean

that everything is perfect.
It means that you've
decided to look beyond the
imperfections."
Anonymous
S
ally is a 50-year-old woman who is slightly plump. At her
recent full-body checkup, her family doctor, Dr Lee, found
that Sally had mild hypertension and high cholesterol, and
advised her to embark on a healthy lifestyle regime. This included
exercise, a balanced diet and managing her stress level. Sally told
Dr Lee that it was very difficult for her to exercise or eat healthily.
Although she wished to lose some weight, she loved to eat and
she felt her body couldn’t take it if she exercised. This chapter
illustrates how Dr Lee used motivational interviewing strategies
to help Sally think about change and take steps towards change.
What is Motivational Interviewing?
Motivational interviewing (MI) is a directive, patient-centered

counselling approach that enhances motivation for change
by helping the patient clarify and resolve ambivalence about
behavioural change.
Motivational Interviewing 43
y
QUOTE
MILLER AND ROLLNICK (1991)
“Motivational interviewing is a way of being with a client, not just a

set of techniques for doing counselling.”
The concept of MI evolved from experience in the treatment of

problem drinkers, and was first described by Miller (1983) in an
article published in Behavioural Psychotherapy. These concepts
and approaches were later elaborated by Miller and Rollnick (1991)
in a detailed description of clinical procedures.
The role of the doctor in MI is directive, and to elicit self-motivational

statements and behavioural change from the patient. In addition the
doctor tries to create in the patient, a state termed discrepancy, in
order to enhance motivation for positive change (Davidson, 1994;
Miller and Rollnick, 1991). Essentially, MI is believed to activate the
capability for beneficial change that everyone possesses (Rollnick
and Miller, 1995). Although some people can change on their own,
others require more formal intervention and support.
The goal of MI is to amplify discrepancy between present behaviour

and broader goals, in order to create cognitive dissonance.
COGNITIVE DISSONANCE
WHERE WHERE ONE

ONE IS WISHES TO BE
44 Chapter 3
BEHAVIOUR
THE FRAMEWORK OF CHANGEINTERVIEWING (MI)
MOTIVATIONAL
SPIRIT of MI
Autonomy
Collaboration
Evocation PRINCIPLES
of MI
Roll with Resistance
Express Empathy
MICRO-SKILLS Develop Discrepancy
in MI Support Self-Efficacy
Open-ended Questions
Reflective Listening
Affirmation CHANGE TALK
Summaries in MI
Desire
Ability
COMMITMENT Reason
LANGUAGE of MI Need
Commitment
Activation
Taking Steps
BEHAVIOUR
CHANGE
What Exactly is the Spirit of Motivational Interviewing?
It is vital for any doctor who practices MI to understand the spirit

of MI. The spirit of this method is characterised in a few key
points (Rollnick and Miller, 1995):
Motivation to change is elicited from the patient, and not imposed

from without
It relies upon identifying and mobilising the patient's intrinsic values
and goals to stimulate behavioural change. E.g. the patient may
say, “I wish to stop alcohol use because I want to be a responsible
father.”
The alliance between doctor and patient is collaborative

It uses an empathic, supportive, non-judgmental, non-
confrontational, non-adversarial, yet directive style. It provides
conditions in which change can occur and builds on the foundation
of Carl Rogers’ humanistic perspectives (Nelson-Jones, 2006).
This is a patient-centered approach which believes that people are
capable of change, with the help of appropriate interactions that
drive the process of change, especially where motivation is the key
factor. To use a metaphor, the patient and doctor are as if working
together on a jigsaw puzzle.
The doctor is directive in helping the patient examine and resolve

ambivalence
Ambivalence is a common response observed in any change process.
It is normal and constitutes an important obstacle to any form of
change. It takes the form of conflict between two courses of action,
each of which has perceived benefits and costs associated with it.
Many patients have never had the opportunity of expressing the
46 Chapter 3
often confusing, contradictory and uniquely personal elements of

this conflict. The doctor's task is to facilitate expression of both
sides of the ambivalence struggle, and guide the patient toward an
acceptable resolution that triggers change. E.g. the patient may say,
“I want to start exercising as it is good for my health, but I am too
unfit to exercise and I am not sure if I have the time.”
Direct persuasion is not used in MI for resolving ambivalence

Persuasion tactics generally increase patient's resistance and
diminish the probability of change (Miller, Benefield and Tonigan,
1993; Miller and Rollnick, 1991). E.g. the doctor using direct
persuasion may say, “You should change; it is the only way that will
work for you.”
The counselling approach is generally a gentle and eliciting one

Aggressive confrontation and argumentation are not practiced
in MI. To a doctor who is accustomed to confronting and giving
advice, MI may appear to be a hopelessly slow and passive process.
However the evidence of MI is in the outcome. More aggressive
strategies, sometimes guided by a desire to “confront the denial”, can
easily slip into pushing patients to make changes for which they are
not ready. E.g. a confrontational doctor may say, “Stop whining over
your problem, just do something about it.”
Readiness to change is not a client trait, but a fluctuating product

of interpersonal interaction
The doctor is therefore highly attentive and responsive to the
patient's motivational signs. Resistance and denial are seen not as
the patient traits, but as feedback regarding the doctor's behaviour.
Resistance is often a signal that the doctor is assuming greater
readiness to change on the part of the patient than is the case, and
it is a cue that the doctor needs to modify motivational strategies.
AN ILLUSTRATION OF CONFRONTATIONAL APPROACH

VERSUS MI APPROACH
OPPOSITE APPROACH FUNDAMENTAL APPROACH

TO MI OF MI
Confrontation Collaboration
Conversation involves over- Conversation involves a
riding the patient's impaired partnership that honors
perspectives by imposing the patient's expertise and
awareness and acceptance of perspectives. The doctor provides
“reality” that the patient cannot an atmosphere that is conducive
see or will not admit. rather than coercive to change.
Education Evocation
The patient is presumed to lack The resources and motivation
the key knowledge, insight, and/ for change are presumed to
or skills that are necessary for reside within the patient. The
change to occur. The patient intrinsic motivation for change
seeks to address these key is enhanced by drawing on the
deficits by providing information. patient's own perceptions, goals,
and values.
Authority Autonomy
The doctor tells the patient what The doctor affirms the patient's
he or she must do. right and capacity for self-
direction and facilitates informed
choice.
48 Chapter 3
Which Micro-skills (or Fundamental Interaction

Techniques) are useful in MI?
Successful MI always starts with the building of a strong therapeutic

alliance with the patient. The basic approach to interactions in MI is
summarised in the acronym OARS (Miller and Rollnick, 1991; Miller,
Zweben, DiClemente & Rychtarik, 1992):
O pen Questions A ffirmations
R eflections S ummaries
These techniques can be used comfortably, regularly and

consistently, as part of a basic foundation of forming interpersonal
relationships with your patient in every session.
Open-ended Questions
• Asking open-ended questions helps you understand your
patient's point of view and elicits his or her feelings about a
given topic or situation.
• Open-ended questions facilitate dialogue; they cannot be
answered with a single word or phrase and do not require
any particular response. They are a means to solicit additional
information in a neutral way.
• Open-ended questions encourage the patient to do most
of the talking, prevent the doctor from making premature
judgments and keep communication moving forward.
• Examples of open-ended questions: “What brings you here

today?”, “Tell me what’s been happening since we last met”,
“What makes you feel that it might be time for a change?”
A
TIP
HOW TO ASK OPEN-ENDED QUESTIONS
Close-ended Questions Open-ended Questions
• So you are here because • Tell me, what brings you

you are concerned about here today?
your high blood pressure?
• Do you have children? • Tell me about your family.
• Do you agree that it would • What do you think about

be a good idea for you to the possibility of going to
see a counsellor? see a counsellor?
• Do you like to smoke? • What are some of the things
you enjoy about smoking?
• Does your behaviour affect • How does your behaviour

your family? affect your family?
• Do you think you drink too • In what ways are you

often? concerned about your
drinking?
Affirmations
• Affirmations are positive reinforcements, or statements of
a patient's behaviour that deserves recognition. When a
particular behaviour is acknowledged, the pride that the
patient feels from its recognition can lead to repetition of that
positive behaviour.
50 Chapter 3
• Affirming the patient can encourage, empower and support

him or her through the change process. Affirmation builds self-
confidence in the patient's belief that he or she can change,
hence reinforcing self-efficacy.
• For affirmation to be meaningful, it must be genuine, congruent
and appropriate to the positive behaviour.
• An example of affirmation: “It takes great courage to share
your story and to be so open and honest to a stranger.”
A
TIP
EXAMPLES OF AFFIRMING RESPONSES
• I appreciate that you are willing to meet me today.

• You are clearly a resourceful person.
• You handled yourself really well in that situation.
• That’s a good suggestion.
• If I were in your shoes, I don’t know if I could have managed
nearly so well.
Reflective Listening
• Reflective listening is an essential practice in building rapport.
It is a fundamental component of motivational interviewing
in which the doctor demonstrates accurate understanding of
the patient's communication by restating it.
• Reflective listening is a way of checking rather than assuming
that one knows what is meant (Miller & Rollnick, 2002). It
strengthens the empathic relationship between doctor and
patient, and also encourages exploration of deeper problems
and feelings.
• Some examples are listed in Appendix A on reflective listening,

how to roll with resistance, reframing and more complex
reflection techniques in different circumstances.
ATIP
SOME STANDARD PHRASES IN REFLECTIVE LISTENING
• So you feel…
• It sounds like you…
• You’re wondering if…
• So what I hear you saying is…
• This is what I am hearing; please correct me if I am wrong…
Summarising
• Summaries are a form of reflective listening where the doctor
reflects to the patient what he or she has been saying.
• Summaries can be used throughout a conversation but are
particularly helpful at transition points. E.g. if you are in a
lengthy conversation with a patient, you may summarise at
some point to ensure you are on track with where the patient
is going, and then continue with the conversation.
• Summarising enhances building of rapport, or call for attention
or direction towards an important point. Doing it frequently
is helpful, as too much information from the patient can
be unwieldy for the doctor to digest and feedback. If the
interaction is going in an unproductive or problematic
direction, for instance when encountering resistance, the
summary can be used to shift focus of the interaction.
52 Chapter 3
A
TIP
EXAMPLES OF SUMMARIES
(You can begin with a statement indicating you are making a

summary):
• Let me see if I understand so far…
• Here is what I’ve heard. Tell me if I’ve missed anything.
• What you’ve said is important. Let me re-cap.Here are the
salient points that you have just shared.
An illustration on the application of OARS is provided in Appendix

A on how Dr Lee used the reflection techniques and summarising
to facilitate her change talk with Sally.
How Does the Clinician Identify Change Talk in MI?

The goal of using OARS is to move the patient forward by eliciting
change talk, or self-motivational statements.
Change talk refers to the doctor's ability to recognise the patient's

response and discussion of his or her ‘desire’, ‘ability’, ‘reason’, and
‘need’ to change behaviour and what will give rise to a commitment
to change – in the acronym DARN-C. (Amrhein, Miller, Yahne,
Palmer & Fulcher, 2003; Sciacca, 2009). Examples are given in
Appendix D.
THE DARN-C MODEL
Desire Ability Reasons Needs Commit-

ment
Change talk involves statements or affective communications that

indicate the patient is considering the possibility of change. The
doctor actively listens for:
• Change talk in its various strengths (from weak to strong or

committed)
• Whether the patient talks about commitment to change (intention,
decision)
• Activation to change (readiness and preparation)
• Whether the patient is taking steps to change (plans and
actions)
Miller and Rollnick (1991, 2002) organised this change talk process
in four categories. Sample questions on Evoking Change Talk (Miller
and Rollnick, 1991) are listed in Appendix B:
• Client’s ability to recognise the problem
• Client’s concern of the problem
• Client’s commitment to change
• Client’s belief that change is possible
Essentially, any statement oriented towards the present or future,

either in the cognitive or emotional realm, may represent a self-
motivational statement. E.g. “I think that smoking may be causing
problems” (present-cognitive); “I’m kind of worried that things may
be getting out of control” (present-emotional); “I’m definitely going
to do something about that” (future-cognitive); “You know, I’m
starting to feel like this just might work out” (future-emotional).
54 Chapter 3
How Can Change Talk Be Mobilised to Commitment

and Activation?
Mobilising change talk signals movement towards resolution of the

ambivalence in favor of change. It means that change talk – wants to,
can, has reasons to or must change – is not the same as saying one
will change. The doctor's observation of the patient's commitment
language can give a good gauge on the patient's readiness to put
action on change.
The commitment to change language (Miller and Rollnick, 2013) is

described as follows:
COMMITMENT
n • Committing language signals the likelihood of

action. Commitment language is when the patient
says, “I will, I promise, I guarantee, I give my word…”
• “I want to, I could, I have good reasons to, I need
to…” may not be commitment language.
ACTIVATION
S • Activation language indicates movement towards

action, yet is not quite a commitment to do it. It
signals that the patient is leaning in the direction of
action – “I’m willing to…I am ready to…I am prepared
to…”
• The doctor can respond to such talk with questions
such as: “When will you do it?” or “What exactly are
you prepared to do?”
• Activation language is a sign of the patient being
“almost there” and implies a commitment without
actually stating it.
TAKING STEPS
4 • This is also an activation language that indicates

that the patient has already done something in
the direction of change. E.g. “I bought a pair of
running shoes for exercising” or “I started a food
diary” or “I went to see a dietician to plan a healthy
diet for me”.
• Taking steps does not necessarily indicate a
commitment to change, but the key is to listen for
language that signals movement towards change.
How Can the Principle of Motivational Interviewing be Used

to Deal With Ambivalence?
Ambivalence is observed to be one of the key barriers in motivation

to change. It is a common thought and behavioural process observed
in every patient when he or she thinks about change.
The doctor needs to identify the ambivalence when it is presented

by the patient. E.g. the patient may say, “If I start to watch what I
eat, I may feel better about myself, but I may also feel unhappy that
I cannot choose to eat the food I like.”
A
NOTE
AMBIVALENCE
Having opposite feelings and emotions at the same time.

56 Chapter 3
The doctor could adopt the five key strategies to address ambivalence
in thought and behaviour. It is summarised in the acronym ‘DEARS’
(Miller and Rollnick, 1991):
D evelop
Discrepancy
E xpress
Empathy
A void
Argumentation
R olling with
Resistance
S upport
Self-efficacy
D evelop discrepancy between the patient's goal or values and

current behaviour
This is a strategy that uses comparison on the positives and negatives

of the behaviour. This process develops the patient's awareness of the
consequences, and helps client examine the need for change. The doctor
uses pros and cons discussion to develop discrepancies between the
patient's goals and his or her current behaviour. Often the patient will
present arguments for change and doctor's task is to acknowledge and
empower self-motivational statements.
Express empathy through reflective listening

Expressing empathy is one of the essential and defining characteristics of
MI. It is a specifiable and learnable skill the doctor uses to demonstrate
understanding of the patient's meaning through reflective listening (as
discussed in OARS). An empathic style involves communicating respect
and acceptance of the patient and his or her feelings. The doctor
encourages a supportive, trusting, non-judgmental and collaborative
relationship. In some instances, the doctor is seen as a knowledgeable
consultant; sincerely complimenting instead of denigrating the patient.

The doctor tends to listen more, instead of giving direct advice, hence
establishing a safe and open environment that is conducive to examining
issues and eliciting personal reasons and methods for change. A key
component of MI is an accurate understanding of the patient's unique
perspective, feelings and values.
Avoid argumentation and direct confrontation

It is tempting to argue with a patient who is unsure about change
or unwilling to change, especially if the patient is hostile, defiant or
provocative. However, trying to convince a patient that a problem
exists or that change is needed could precipitate even more resistance.
Arguments with the patient can rapidly degenerate into power struggle
and do not enhance motivation; instead, they are counterproductive
to change process. The doctor needs to observe cues of the patient's
defensiveness in the conversation. Resistance is a signal to change
strategies or directions. The doctor should avoid imposing and pushing
for change or unnecessary labeling e.g. telling the patient “You are in
denial.” MI advocates starting with wherever your patient is, and altering
self-perceptions not by arguing or confronting, but through substantially
more effective means of change talk.
R olling with resistance is adjusting to the patient's resistance

rather than opposing the patient directly
Resistance is an important concern for the doctor because it is

predictive of poor treatment outcomes and lack of involvement in the
therapeutic process (Miller, Zweben, DiClemente, & Rychtarik, 1992).
Resistance is a signal that the patient views the situation differently.
Hence this requires the doctor to put effort to understand the patient's
perspective and proceed from where they are. It is a signal to change
direction or listen more carefully. It offers the doctor an opportunity to
58 Chapter 3
respond in a new way and to take advantage of the situation without

being confrontational. Adjusting to resistance is similar to avoiding
argumentation; it offers another opportunity to express empathy by
remaining non-judgmental and respectful, encouraging the patient to
talk and stay involved.
There are four common types of resistance highlighted by Miller and

colleagues (see Appendix D). These are:
• Arguing
• Interrupting
• Denying
• Ignoring
The doctor can use reflective listening techniques to react appropriately

to resistance (examples shown in Appendix A).
Support self-efficacy and optimism

Many patients do not have a well-developed sense of self-efficacy and
find it difficult to believe that they can begin or maintain behavioural
change. Reinforcing self-efficacy requires eliciting and supporting hope,
optimism and the feasibility of accompanying change (Sobell & Sobell,
2003). This requires the doctor to recognise the patient's strengths
and bring these into conversation whenever possible. Unless a patient
believes change is possible, the perceived discrepancy between the desire
for change and feelings of hopelessness about accomplishing change is
likely to result in rationalisation or denial, in order to reduce discomfort.
Because self-efficacy is a critical component of behaviour change, it
is crucial that as a doctor you also believe in the patient's capacity to
reach his or her goals. Education can increase the patient's sense of
self-efficacy. Credible, understandable, and accurate information helps
the patient understand more about his or her situation.
More examples on the use of “DEARS” are illustrated in Appendix E

(Source: Sobell & Sobell, 2003).
APPENDIX A-I
Other Complex Reflection Techniques:
In dealing with the patient's resistance, here are some strategies
using different reflection techniques:
1. Simple Reflection– One way to reduce resistance is simply to

repeat or rephrase what the patient has said. This communicates
that you have heard the person, and that it is not your intention
to get into an argument with the person.
Sally: “But I can’t exercise. My body is

so heavy, I cannot take it.”
Dr Lee: “Exercising seems nearly
impossible because you feel your body is
too weak and unfit.”
Sally: “That’s right, but I think what you say is
true too, that I should start exercising.”
2. Amplified Reflection– The doctor can amplify or exaggerate the

reflection points, where the patient may disavow or disagree with
it. It is important that the doctor does not overdo it, because if
the patient feels mocked or patronised, it may provoke an angry
response.
Sally: “But I can’t change my diet. As I

really like sweets and desserts.”
Dr Lee: “Hmmm, I see. So you really can’t change your
diet because you feel the sweets and desserts are the
main meals that your body needs and you may not
survive without them.”
Sally: “Well, they are not really the main meals

needed by my body, they are just indulgence, I
don’t think my body needs it to survive.”
60 Chapter 3
APPENDIX A-II
3. Double-sided Reflection– The doctor reflects both current

resistance statement, and a previous contradictory statement that
the patient has made.
Sally: “But I can’t exercise. My body is so

heavy, I cannot take it.”
Dr Lee: “You can’t imagine exercising, and at

the same time you’re concerned about how
your weight is affecting your physical health.”
Sally: “Yes, I guess you are right, I do have

mixed feelings about it.”
4. Shifting Focus with Reflection– This is another way to reduce

resistance. It is often not productive to address resistant or
counter-motivational statements; instead goals may be better
achieved by simply not responding to the resistant statement.
Sally: “But I can’t change my diet. I really like

sweets and desserts.”
Dr Lee: “You are getting way ahead of the
topic here. I’m not talking about quitting your
sweets completely. We are talking about
healthier diet choices.”
APPENDIX A-III
5. Shifting Focus with Reflection– is a way to avoid argument that is

counter-productive to change talk. There is a paradoxical element
in this, which often will bring the patient back to a balanced or
opposite perspective. This strategy can be particularly useful
with patients who present in a highly oppositional manner and
who seem to reject every idea or suggestion.
Sally: “But I can’t exercise. My body is

so heavy, I cannot take it.”
Dr Lee: “Well, after our discussion, you may
decide that exercise might not be the best
option for you, as it may be too difficult to
start doing it.”
6.
Reframing– a reflection strategy in which the doctor invites the
patient to examine his or her views in a new perspective. By doing
this, new meaning is given to what has been said.
Sally mentioned her mother did not understand and nagged

at her a lot about her health and weight. Sally may view her
mother as “always telling me what to do.”
Dr Lee reframed this as: “Your mother must care

a lot about you to tell you something she feels
is important to you, even knowing that you will
likely get angry with her.”
62 Chapter 3
APPENDIX A-IV
A
TIP
EXAMPLES OF SUMMARIES FOR APPENDIX A
Examples of Summaries
(Begin with a statement indicating you are making a summary):
• Let me see if I understand so far…
• Here is what I’ve heard. Tell me if I’ve missed anything.
• What you’ve said is important. Let me re-cap.
• Here are the salient points that you have just shared.
Dr Lee’s summary to Sally:
“Let’s stop for a moment and summarise what we’ve just talked
about. You are saying you are not sure that you want to change
your lifestyle because there are a lot of adjustments to make. At
the same time, you have some concerns about the worsening of
physical and mental health. Did I miss anything?”
The goal is not to acquire ammunition, which will then be turned

on Sally’s defenses in an overwhelming manner. Instead, it should
be to reflect what Sally had said and encourage Sally to supply the
meaning. This is an area where it requires the doctor's attentive
listening to the patient's understanding of the problem. It is this
understanding that will guide the patient's effort to change or
maintain status quo.
APPENDIX B
Evoking Change Talk
(Source: Miller and Rollnick, 1991)
CONCERN
• What is there about your
behaviour that you or other
PROBLEM RECOGNITION people might see as reasons for
• What makes you think that this is a concern?
problem? • What worries you about your
• What difficulties did you encounter current behaviour?
in relation to your current behaviour? • What can you imagine happening
• In what ways have other people to you?
been affected by your behaviour? • How much does this concern you?
• In what ways has this behaviour • In what ways does this concern
been a problem for you? you?
• How has this behaviour prevented • What do you think will happen
you from doing what you want to do? if you don't make a change?
OPTIMISM INTENTION TO CHANGE

• What makes you think • The fact that you're here indicates that
that if you decide to make at least part of you think it's time to do
a change, you could do it? something.
• What encourages you • What are the reasons you see for making
that you can change if a change?
you want to? • What makes you think that you may need
• What do you think would to make a change?
work for you, if you • If you were 100 per cent successful and
needed to change? things worked out exactly as you would
like, what would be different?
• What makes you think that you should
keep this behaviour the way as it is? What
makes you think it's time for a change?
• I can see that you're feeling stuck at the
moment. What's going to have to change?
64 Chapter 3
APPENDIX C-I
Listening to Change Talk

Change talk can be classified into five categories - Desire, Ability, Rea-
son, Need, and Commitment (DARN-C). Learning to listen for the sub-
tleties of meaning in the patient's conversation in these five categories
is a very important practice in MI, as it will help the doctor to decide
which strategies work best for the patient.
These questions are additional resources to elicit change talk focusing

on DARN-C categories:
DESIRE: Why would you want to make this change?
ABILITY: How would you do it if you decide to change?
REASON: What are the three best reasons?
NEED: How and why is it important?
COMMITMENT: What do you think you’ll do?
Here are some examples of how conversations might go with Sally:
DESIRE
"If you were going to change your lifestyle, why

would you do it?"
"Well, my mother has been nagging me, and

I’m beginning to think she is right. I’ve got to
do something or my health just won’t take it
anymore, since now I have hypertension and high
cholesterol. Besides, my stamina is very poor, I
get breathless just by taking a few flight of steps."
Doctor
"So, you’re thinking your mother might be right
about your unhealthy lifestyle and it is affecting
Sally
your health."
APPENDIX C-II
ABILITY
"I know you are not ready to stop your desserts and
sweets, but if you were, what are some things you
would do?"
"It would be very hard for me, because I love my
desserts and sweets. I’d have to start by cutting
back to just take them on weekend."
Doctor "While it would be hard for you to cut back, it

seems like just eating your sweets and desserts
only on weekend might be a place to start." Sally
REASON
"Can you give me three good reasons why you

might consider changing your lifestyle?"
"Oh, if you talked to my mother, she’d tell you

more than three reasons! She has been nagging
again. She says I’m so unfit that I will just collapse
with stroke or heart attack at a young age. Now
knowing my blood pressure and cholesterol is high,
she will sure nag non-stop. But I guess she is right
Doctor about it, as my health is suffering now."
"It seems that your mother is very concerned

Sally
about you and your health."
66 Chapter 3
APPENDIX C-III
NEED
"How important would you say changing your

lifestyle is right now?"
"Maybe…not very important yet."
"Why do you say that?"
"I have so many other worries such as work."
"It seems to you that your lifestyle is not the most
important thing right now. What would have to
Doctor happen to make it more important?"
"I think if I had a life-threatening health Sally
condition, or an illness which affects my job,
it might get my attention."
COMMITMENT
"I’m not sure. I could try what my best

friend is doing, which is to sign up for a gym
membership, just to see what it’s like."
Doctor "What do you think you’ll do about changing

your lifestyle? What ideas do you have for
yourself?" Sally
In each of these conversations, the doctor responded with reflective

statements, which summarise the change talk statements the patient
made. This is an additional technique which the doctor can use in
conjunction with the practice of OARS presented in Appendix A. It
is important to understand that the doctor would acknowledge the
statements that are on the “no change” side of the ambivalence, but
reinforce the change talk.
APPENDIX D-I
4 Types of Resistance
ARGUING (The patient contests the accuracy, expertise, or integrity

of the doctor.)
• Challenging — The patient directly challenges the accuracy of what
the doctor has said.
• Discounting — The patient questions the doctor's personal
authority and expertise.
• Hostility — The patient expresses direct hostility towards the
doctor.
INTERRUPTING (The patient breaks in and interrupts the doctor in

a defensive manner.)
• Talking over — The patient speaks while the doctor is still talking,
without waiting for an appropriate pause or silence.
• Cutting off — The patient breaks in with words obviously intended
to cut the doctor off.
DENYING (The patient expresses unwillingness to recognise

problems, cooperate, accept responsibility, or take advice.)
• Blaming — The patient blames other people for problems.

• Disagreeing — The patient disagrees with a suggestion that
the doctor has made, offering no constructive alternative. This
includes the familiar "Yes, but...," which explains what is wrong
with suggestions that are made.
68 Chapter 3
APPENDIX D-II
• Excusing — The patient makes excuses for his or her behaviour.

• Claiming impunity — The patient claims that he or she is not in
any danger from continuing in that behaviour.
• Minimising — The patient suggests that the doctor is exaggerating
risks or dangers and that it really isn't so bad.
• Pessimism — The patient makes statements about himself or
herself or others that are pessimistic, defeatist, or negative in
tone.
• Reluctance — The patient expresses reservations and reluctance
about information or advice given.
• Unwillingness to change — The patient expresses a lack of desire
or an unwillingness to change.
IGNORING (The patient shows evidence of ignoring or not following

the doctor.)
• Inattention — The patient's response indicates that he or she has

not been paying attention to the doctor.
• Non-answer — In answering a doctor's query, the patient gives a
response that is not an answer to the question.
• No response — The patient gives no audible verbal or clear
nonverbal reply to the doctor's query.
• Side-tracking — The patient changes the direction of the
conversation that the doctor has been pursuing.
APPENDIX E-I
Examples of "DEARS"
(Source: Sobell & Sobell, 2003)
I Developing Discrepancy through

DECISIONAL BALANCING
Decisional balancing strategies can be used anytime throughout

session. A good strategy is to give the patient a written Decisional
Balance (DB) exercise at the beginning of the session and ask the
patient to bring the completed exercise on the subsequent session.
The DB exercise asks the patient to evaluate his or her current
behaviour by simultaneously looking at the good and not so good
things about his or her actions.
The goal for the patient is twofold: to realise that (a) there are
some benefits from the problem behaviour and (b) there will be
some costs if the patient decides to change that behaviour.
Talking with patients about the good and not so good things they
have written down on their DB can be used to help them understand
their ambivalence about changing and to move them further toward
wanting to change. The doctor can do a DB exercise with the patient
by simply asking in an open-ended fashion about the good and not
so good things regarding the problem behaviour and what it would
take to change that behaviour (a sample of DB worksheet is attached
below).
The doctor could say:

• Tell us some good things and not so good things about your
behaviour?
• How do you think your life would be different if you were to
change?
• What do you see your life to be if you don’t make changes
and continue the same behaviour?
70 Chapter 3
APPENDIX E-II
• How does your _________ fit in with your goals?

• On one hand, you say that your ___________ are important to
you, yet you continue to ______________, help me to understand…
• What do you feel you need to change to obtain your goals?
• How will things be for you a year from now if you continue to
_________?
• Hypothetically speaking, if you were to make a change in any
area of your life, what would it be?
A
TIP
A SAMPLE OF DECISIONAL BALANCE WORKSHEET
When we think about making changes, most of us don’t

really consider all “sides” in a complete way. Instead,
we often do what we think we “should” do, avoid doing
things we don’t feel like doing, or just feel confused or
overwhelmed and give up thinking about it all. Thinking
through the pros and cons of both changing and not
making a change is one way to help us make sure we have
fully considered a possible change. This can help us to
“hang on” to our plan in times of stress or temptation.
Below, write in the reasons that you can think of in each of

the boxes. For most people, “making a change” will probably
mean quitting / stopping _____________(behaviour), but it
is important that you consider what specific change you
might make, which may be something else.
(Refer to the worksheet on the next page)

APPENDIX E-III
Decisional Balance Worksheet
BENEFITS/PROS COSTS/CONS
Making A
Change
Not Changing
II Expressing EMPATHY

• I understand how difficult this is…
• Yes, making changes is hard work…it is VERY hard work!
• I know where you’re at with this.
• That must have been hard on you.
72 Chapter 3
APPENDIX E-IV
III Amplifying AMBIVALENCE

• How has your behaviour been a problem to you? How has it
been a problem for others?
• What was your life before you started having problems with __________?
• If you keep heading down the road you’re on, what do you see
happening?
IV Rolling with RESISTANCE

• That is OK if you don’t want to change…it is your choice.
• Maybe you aren’t ready to change.
• What do you want to do? How do you want to proceed?
• Where do you want to go from here?
V Supporting SELF-EFFICACY

• It seems as though you have put a lot of thought into your goals…
• You have a good plan of action…
• It sounds like you are still struggling with making these
changes, but you have had some success at making some.
• It sounds like you have made real progress. How does that
make you feel?
1. MI is a technique in which the doctor can take on a more

directive role, and become the enabler in the change
process.
2. The doctor's goal is to elicit self-motivational statements
from the patient in addition to creating discrepancy, in order
to enhance motivation for positive change.
3. It is a collaborative relationship between the doctor and the
patient.
4. MI can be used to resolve the ambivalence that prevents
the patient from realising his or her goals.
5. MI builds on Carl Rogers’ optimistic and humanistic theories
about believing people’s capabilities for exercising free
choice and changing through a process of self-actualisation.
6. MI seeks to understand the patient's frame of reference,
particularly through reflective listening, expressing
acceptance and affirmation.
7. The doctor closely monitors the patient's degree of readiness
to change, ensuring that resistance is not generated by
jumping ahead of the patient.
8. Even for patients with low readiness or lack of motivation,
MI can serve as a prelude to therapeutic work.
74
Chapter 4
Cognitive
Behavioural Therapy
76 Chapter 4
“ It's not what happens

to you but how
you react to it that
matters."
Epictetus
J
ohn visited his family doctor for the fourth time in a
fortnight, each time presenting with different and vague
symptoms and requesting a medical certificate to excuse
him from work. Having treated him more than 10 years, his doctor
noticed that John looked quite downcast and low-spirited recently.
Upon further probing, he learnt that John had ended a long-term
relationship a few months ago. He lost interest in activities he used
to enjoy, and expressed that he felt “useless” and undeserving of
love.
Emily had always seemed quite anxious and tended to worry a

lot about things. At her visit to the doctor, she shared that she
had been having a number of things on her plate, including her
son’s upcoming school examinations, her mother’s ill-health, and
a new project at work. As a result, she had been experiencing
palpitations and nervous tension. Besides referring her for further
investigations, her family doctor also thought she might need help
in managing her anxiety.
This chapter will apply the concepts and framework of Cognitive

Behavioural Therapy to understand John’s and Emily’s problems.
Brief interventions suitable for primary care will also be introduced.
Cognitive Behavioural Therapy 77
What is Cognitive Behavioural Therapy?
Cognitive behavioural therapy, or CBT for short, is a form of

therapy originally developed to treat depression. It has since
been extended and used for a wide range of other psychological
problems including anxiety, eating disorders, and obsessive
compulsive disorder. Extensive research has shown that combining
CBT with pharmacotherapy is more efficacious that either form of
therapy alone for the treatment of psychological conditions such as
depression and anxiety.
The Power of Perception
CBT combines concepts from both behavioural therapy and cognitive

therapy. The fundamental theory in CBT argues that emotional
and psychological problems arise from negatively-biased thinking
i.e. emotions do not occur because of an event; rather, they come
about from our perception and interpretation of an event. The
resulting emotions influence our actions and behaviours, which in
turn further impact on our emotions. In this way, thoughts, emotions,
behaviours, and physiology influence each other in a unified system.
This is illustrated in Figures 1 and 2. The goals of CBT are, therefore,
to change unhelpful and biased thoughts and behaviours in order to
change emotions.
y
QUOTE
WILLIAM JAMES
“The greatest weapon against stress is our ability to choose

one thought over another.”
78 Chapter 4
FIGURE 1 - CBT MODEL (I)

Thoughts, behaviours, emotions and physiology mutually influence and
interact with each other
Activating Event
Cognition (Interpretation)
What our minds say
Behaviour Emotion
What we do How we feel
Physiology
Bodily sensations experienced
FIGURE 2 - CBT MODEL (II)

Case example of the CBT model. Emily’s automatic thoughts that
arise from the activating event cause her to feel anxious and trigger
physiological reactions in her body. The thoughts also cause her to
engage in unhelpful behaviours that perpetuate her problem and result
in more worrying. The palpitations may also bring on more anxiety, and
hence more palpitations. In this way, various components of the model
have reciprocal influences on each other.
Activating Event
Emily has been given a task to
complete within a tight timeframe
Cognition (Interpretation)
"I can't do this", "There isn't enough time", "What if
I don't produce a satisfactory piece of work?"
Behaviour
Emotion
Procastinate, over-
prepare, worry more, Anxiety
check excessively
Physiology
Palpitations, muscle tension
80 Chapter 4
Principles and Characteristics of CBT
Therapeutic work in CBT is based on a shared formulation, or

case conceptualisation. The doctor uses the CBT framework to
understand what causes and maintains the patient’s problems,
and shares this with the patient. This is made possible through
good therapeutic alliance and a collaborative approach between
doctor and patient. At the core of CBT, the unhelpful thinking
is examined and questioned through techniques that guide the
patient to self-discovery, rather than lecturing, persuading, or
debating. A range of behavioural and cognitive strategies are used,
depending on the patient’s presenting issues. Throughout this,
the doctor explains the rationale and process of each exercise, to
teach the patient to become his own therapist.
How will CBT be useful for my Family Practice?
CBT has been adapted for use in primary care with promising results.
Given its time-limited nature, it is possible to use CBT as a brief
intervention. The wide range of behavioural and cognitive techniques
allows the doctor to pick and choose interventions. Often, patients
may resist being referred to mental health specialists, have to face
with long waiting times for specialist treatment, or are limited by
resources e.g. money, time, accessibility. The psychoeducation
components of therapy can build insight in the patient that may
encourage further help-seeking behaviours. The collaborative
nature empowers the patient to start taking small steps for self-
help, rather than rely entirely on the doctor for a “cure”.
What are some Prerequistes and Contraindications

for CBT?
In order to engage in the CBT techniques, patients need to have

some accessibility to their thoughts and be able to identify and
report them. Some level of emotional awareness is also required
e.g. ability to recognise, differentiate, and name emotions. If these
are not present, it is recommended that patients first build up such
skills through monitoring records such as a mood diary. CBT should
also be used only when the doctor has reasonable rapport with the
patient to be able to trust and engage with the doctor. CBT is also
most suitable for patients with mild to moderate levels of emotional
and psychological disturbances. If patients are acutely unwell to the
extent that they are unable to engage, pharmacotherapy or other
forms of therapy should be considered first.
What about the Case Formulation?
The case formulation helps us make sense of the problem.

Information is collected by carrying out a thorough and focused
interview with the patient. The doctor identifies factors that make
the patient vulnerable to experiencing this problem (background
and predisposing factors), what triggered the problem (precipitating
factors), what processes and issues are maintaining the problem
(perpetuating factors), and what positive aspects can be harnessed
upon in treatment (protecting factors).
The main focus in CBT is usually on the perpetuating factors and

these are usually targeted in therapy by selecting appropriate
interventions to overcome them. The formulation is also shared with
the patient without using jargon (see section on Psychoeducation).
82 Chapter 4
The ABC's of CBT
The ABC framework helps the doctor and patient identify triggers,
thoughts, emotions, and behaviours. These can be elicited either
through direct questioning (see section on socratic questioning) or
monitoring diaries (see Figure 3). This also provides an opportunity
for the doctor to educate the patient on the link between thoughts
and feelings and present the rationale for challenging and changing
thoughts. The doctor may first use an everyday example that is
easily identifiable to the patient, before applying the model to the
patient’s own problems. This is illustrated in Box 1.
FIGURE 3 - AN EXAMPLE OF JOHN'S THOUGHT DIARY
A B C
ACTIVATING EVENT BELIEF CONSEQUENCES
What led to Automatic Thoughts: Emotions, Bodily
the emotional "What was going Reactions and
disturbance through your mind?" Behaviours
John's friend cancelled "I must be quite boring Felt dejected, stayed at
their dinner appointment to be with, nobody likes home, did not attempt
at the last minute to hang out with me" to contact friend again
BOX 1 - EXPLAINING THE THOUGHT-FEELING LINK

using an everyday example with the help of a diagram
Doctor: Imagine this person, A, is walking in a mall and happened to see his
colleague from another department, a few metres away from him. As
his colleague looks over, A smiles and waves at him. But his colleague
doesn’t wave back - what do you think would be going on in A’s mind?
John: Maybe this colleague doesn’t like me, or maybe I’m so insignificant
that he doesn’t remember or recognise me.
Doctor: And how would A feel if he thought that way?

John: Sad.
Doctor: Now imagine A thought something else, like “Wow this guy is rude and
arrogant”. How would A feel?
John: He would probably feel angry.
Doctor: And now, imagine A thought “Oh, maybe he was deep in thought and
didn’t see me”. How would he feel?
John: He wouldn’t feel anything. Just normal.
Doctor: So you see how different thoughts and interpretations can arise
from one single event, and depending on how we think, we will feel
differently, and subsequently act differently.
A B C
ACTIVATING EVENT BELIEF CONSEQUENCES
"I am forgettable and Feel sad, dejected
Bumped into a insignificant"
colleague and waved
to him but he didn't "Maybe he was deep Feel calm, maybe
wave back. in thought and did concerned for
not see me" colleague
84 Chapter 4
The Origins of Automatic Thoughts
Automatic thoughts are what we call self-talk, things we say

to ourselves, or self-statements. These are distinguished from
underlying beliefs and assumptions, or which are overarching beliefs
about oneself, others, and the world. Underlying beliefs guide
information processing, help us organise the world, and shape how
we think, feel, and behave. They are formed from early childhood
and mostly remain dormant until activated by significant events and
triggers e.g. a relationship breakup. When these beliefs are activated,
our interpretations of (i.e. automatic thoughts) and responses to
other related situations will be influenced by these beliefs.
This is illustrated in Boxes 2 and 3 for both John and Emily.

Underlying beliefs are more difficult to elicit and not always
obvious. Sometimes, working on the level of automatic thoughts
is sufficient and it is not always necessary to work with underlying
beliefs. When necessary, further examination and careful
questioning of the activating event and automatic thoughts can
shine light on the underlying beliefs.
BOX 2 - CASE FORMULATION FOR JOHN
Early Experiences: Parental rejection

and not being accepted for who he is.
Beliefs and Assumptions: I'm

unloveable. I don't matter. I'm a
failure.
Critical Events: Relationship breakup.

(Assumptions and beliefs activated
for all other related events.)
Automatic Thoughts: I wasn't a good

partner. I will forever be alone.
Emotions: Low mood, depressed.
Behaviour: Isolate Activating

self, decreased Event: Friend
motivation to cancels a dinner
engage in activities. appointment.
Fewer opportunities Automatic

to experience Thoughts: People
positive feelings don't like me. I'm
and positive social not interesting to
engagement. be with.
86 Chapter 4
BOX 3 - CASE FORMULATION FOR EMILY
Early Experiences: High expectations

placed on her by parents and teachers.
Being taught that failure is bad.
Beliefs and Assumptions: I must

succeed in everything I do. If I fail, it
means I'm useless and bad.
Critical Events: Multiple stressors,

including son's exams, mother's ill-
health, increased workload.
Automatic Thoughts: I can't cope. I

might lose my job. If my son fails his
exams, he will have no future.
Behaviours: Unhelpful Emotions:

worrying (to avoid Anxiety, fear.
emotions triggered from
thinking about worst
fears); Procrastination Perceived as
(do other things to dangerous
distract self and avoid Sensations:
reminders of stressors). Heart
palpitations,
tension.
Does not lead

to solutions or
productive behaviour.
Maintaining Process
As the main focus of CBT is on the present, perpetuating factors (or

maintaining processes) form a crucial component of the formulation.
These are usually understood as vicious cycles in which automatic
thoughts, influenced by activated underlying beliefs, trigger
emotions and sensations, and guide actions and behaviours, that
further feedback to the external event, thoughts and underlying
beliefs, thereby maintaining the emotion and symptoms.
Below is a list of a few common maintaining processes applied to

case examples in Boxes 2 and 3.
1. Reduction of Activity and the Lethargy Cycle

2. Escape and Avoidance
3. Scanning and Hypervigilance
4. Fear of Physiological Sensations of Anxiety
5. Cognitive Distortions
w
REDUCTION OF ACTIVITY AND THE LETHARGY CYCLE
This is a common maintaining process in depression.
Low mood leads to decreased motivation and
energy, and thus a reduction in activity. Inactivity
can have an opposite effect of increasing feelings
of lethargy. In addition, reduction in activities
that used to produce positive feelings (such
as social activities and hobbies) leads to fewer
opportunities to experience these emotions like
enjoyment, satisfaction, achievement, and joy. As
a result, the low mood is maintained.
88 Chapter 4
g
ESCAPE AND AVOIDANCE
This is a common maintaining factor in anxiety.
Situations or places that bring on anxiety are avoided
or escaped from in order to avoid experiencing
anxiety. E.g. someone who gets anxious and
experiences feelings of panic on public transport
might avoid taking public transport. Someone who
fears being judged by others might avoid going to
crowded places. This maintains the problem because
the person does not learn that 1) the symptoms
may not come on, 2) the feared consequences
may not happen, and 3) if they do happen, he or
she will be able to cope and gain confidence from
the experience. Worrying is viewed as a form of
cognitive avoidance, as it allows one to avoid the
somatic experience of anxiety and avoid thinking
about core and deeper fears.
i
SCANNING AND HYPERVIGILANCE
Often seen in people with anxiety, scanning or
being hypervigilant to feared events or symptoms
can have the very effect of making them happen (a
form of self-fulfilling prophecy). E.g. someone who
worries about pain in his leg might subconsciously
rub, pinch, or press on it from time to time to
monitor for pain sensations. These actions might
inadvertently bring on pain. Someone who fears
attracting attention in public may constantly scan
the environment for anyone who might be staring
at her. These actions might in turn make her stand
out and attract stares.
u
FEAR OF PHYSIOLOGICAL SENSATIONS OF ANXIETY
Common bodily changes brought on by the
sympathetic nervous system when one experiences
anxiety include increased heart rate, sweating,
and muscle tension (which can lead to trembling).
Some people can develop a fear of such sensation
and perceive them as dangerous or threatening
(e.g. “I’m having a heart attack”). These fears can
be so intense that they bring on anxiety, which
then makes the sensations stronger, leading to an
upward spiral of increasing anxiety.
c
COGNITIVE DISTORTIONS
Cognitive distortions are also known as thinking
errors, or unhelpful thinking styles. Often, the
automatic thoughts that bring about distressing
emotions tend to seem believable and true at that
point in time, but upon further examination, these
are usually biased, irrational, unhelpful, and lead
to negative emotions. Most people make thinking
errors from time to time. Problems occur when
people are unable to recognise them, regulate
them, and consider alternative ways of thinking.
Therefore, a major component of CBT is to help
the patient identify and recognise these thinking
errors, understand how they influence emotions,
question or challenge them, and derive more
balanced thoughts.
A list of common cognitive distortions can be

found in Table 1.
90 Chapter 4
TABLE 1 - EXAMPLES OF COGNITIVE DISORDERS OR

THINKING ERRORS
Cognitive Distortion and Example

Explanation
All-or-nothing/ black-and-white “If I don’t do this perfectly, it
thinking means I have failed.”
Looking at things at the extremes
rather than on a continuum.
Ultimatums “I never do well at anything”,

Using absolute terms like always, or “Everyone thinks I’m weird”.
never, everyone, no one.
Personalisation and self-blame Someone who thinks, “It’s all

Holding oneself fully responsible my fault, I pulled everyone
for something that one had only down with me”, when his team
partial responsibility (and not full loses in a competition.
control) for.
Catastrophising “If I say something wrong, he

Believing that the worst outcome will not like me, and he will tell
will happen. everyone what a bad person
I am. Then I will not have any
friends.”
Mental Filter Making a conclusion that

Focusing on the negatives and one did not do well in one’s
ignoring or minimising the positive presentation based on a
aspects; not taking into account colleague’s statement, while
the whole picture. discounting positive feedback
from others.
TABLE 1 - EXAMPLES OF COGNITIVE DISORDERS OR

THINKING ERRORS (CONTINUED)
Cognitive Distortion and Example

Explanation
Overgeneralisation Saying that one is a failure in
Using one piece of evidence to all aspects of his life because
make generalised conclusions. he made a mistake in one
piece of work.
Labelling “I’m a loser” or “She’s

Making generalised, all-or-nothing heartless”.
statements about oneself or
others.
Mind Reading “She must think I’m

Making predictions about and incompetent.”
believing that one knows what
others are thinking.
Fortune Telling/ Predicting the “I know I’m going to fail this

Future test.”
Predicting and believing that
things will go badly even before it
happens.
Double Standards Being harsh on oneself

Expecting of oneself what one for making mistakes, but
would not expect of others. pardoning others for making
the same mistakes.
92 Chapter 4
What are the Various Interventions and

Techniques used in CBT?
Socratic Questioning
This is a form of questioning that derives from the Greek

philosopher, Socrates, who taught his students by asking questions
that would lead them to arrive at the answers and conclusions
themselves. In CBT, socratic questioning refers to the technique of
asking questions that 1) the patient knows the answer to, and 2)
draw the patient’s attention to relevant information that he has not
considered. Instead of suggesting these to the patient directly, this
form of gentle and curious questioning encourages the patient to
use what he or she already knows to discover alternative viewpoints
(refer to Box 4).
The aim is guided discovery, rather than changing minds. Questions

are phrased in an inquisitive manner that encourages reflection,
rather than to engage in a debate or point out that the patient
is wrong. An empathic stance should be maintained at all times.
Socratic questioning is used in various stages and techniques in
CBT (see examples in Table 2).
BOX 4 - THE DIFFERENCE BETWEEN

(a) Socratic Questioning and (b) Direct Persuasion or Suggestion
(A) Socratic Questioning
Emily: "I get so worried about making mistakes at work, that I spend so
much time checking and re-checking my work."
Doctor: "And what happens when you do that?"
Emily: "I take even longer to finish the work, have less time for other
work so I have to rush, and it makes me more stressed.
Doctor: "And what happens when you’re stressed?"
Emily: "I get more flustered and I make more mistakes."
Doctor: "So what does this tell you about how checking and re-checking
helps your work?"
Emily: "It actually doesn’t help me. Maybe if I spent less time checking,
I will have more time to do my work and be less stressed and
won’t make so many mistakes."
Doctor: "How can we test that out?"
Emily: "I could check my work only once for the next one week, and
record my stress levels and how many mistakes I actually make."
(B) Direct Persuasion or Suggestion
Emily: "I get so worried about making mistakes at work, that I spend so
much time checking and re-checking my work."
Doctor: "But Emily, do you realise that when you spend too much time
checking, you will take longer to finish your work and have less
time for other work, so you will have to rush to finish the rest of
the work. And this can make you more stressed and flustered,
and so you’ll actually be more likely to make mistakes. So maybe
if you can try to check your work only once through, you might
free up more time for other work, and be less stressed, and in
turn make fewer mistakes."
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TABLE 2 - EXAMPLES OF THE USE OF SOCRATIC

QUESTIONING IN VARIOUS STAGES AND TECHNIQUES OF CBT
CBT Stage / Examples of Questions

Intervention
Assessment and • What was going on in your mind?
Psychoeducation • What happened when you did that?
• When that happens, how do you feel?
• What do you mean when you say that?
• If that were true, what would it mean?
• What does this tell you about ?
Behavioural • What could you do to test that thought?
Techniques • How would we know if this were true?
• What would be the first easiest step to take?
• How can we start?
• What’s the worst that can happen? How can you
prepare for it? What could you do if it happened?
• What did you learn from this experiment?
Cognitive Therapy • What is the evidence that this is true?

• Were there times in the past that this was not true?
• Were there times in the past that someone said
something different to you?
• What would you say to a friend in this situation?
• How does thinking this way help you?
• Now that we have considered other viewpoints, how
likely do you think this will happen?
Psychoeducation
Psychoeducation is the first stage of therapy proceeding from

the assessment phase, and continues to be an ongoing process
throughout therapy.
As CBT is collaborative in nature, the aim of psychoeducation would

be to get the patient “on board” in the treatment process, help the
patient understand the problem and the maintaining factors, and
thereby present a rationale for intervention strategies. The process
comprises a balance of didactic teaching and guided discovery
through socratic questioning.
The following steps are covered in psychoeducation (see Box 5 for

an example):
1. Share information on the problem.

• E.g. What is depression, common symptoms, prevalence,
likely causes (genes-environment or diathesis-stress model).
2. Frame the problem as an exaggeration of normal processes.

• E.g. Fear and worry as a normal process and reaction, but
in anxiety disorders these are exaggerated and become
unhelpful.
3. Discuss the maintaining factors.

• The use of diagrams and arrows helps the patient visualise
these vicious cycles better.
4. Explain what to expect in therapy, how therapy will address

the problem and maintaining factors.
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BOX 5 - EXAMPLE OF PSYCHOEDUCATION ABOUT THE LETHARGY CYCLE

AND EXPLAINING THE RATIONALE FOR BEHAVIOURAL ACTIVATION.
(Refer to Box 1 as well for example of psychoeducation
on thoughts and feelings)
Doctor: "John, you told me that you have been feeling quite down lately,
and as a result you have been staying at home more."
John: "Yes, exactly. I just can’t work up the energy to do anything.

I just lie on the couch all day, staring at the television but not
really watching any show in particular. My room is in a mess, but
I don’t have any motivation to tidy it."
Doctor: "It’s common for people to feel unmotivated and lethargic when
they are depressed. Tell me, John, how do you feel after lying on
the couch for the whole day?"
John: "I feel worse- like I have just wasted another day."
Doctor: "So despite resting on the couch and not doing anything, you
are not feeling more energetic but actually feel worse."
John: "Yes, you’re right."
Doctor: (drawing a diagram as he speaks) "Actually, many people who

are depressed go through this too. When they feel down, they
feel tired and unmotivated, and lose interest in things they
used to enjoy. So naturally, they stop doing these things and
stay at home more, thinking if they get more rest, they will feel
better. However, over time, what happens is they miss out on
all the opportunities to experience joy and satisfaction from
engaging in meaningful activities. They might even start to
blame themselves for being “lazy”. And how do you think this
would make them feel?"
John: "They feel more depressed. Just like me. But what should I do then?"
Doctor: "First, in order to break this vicious cycle, we will get you to
start doing something, even if you don’t feel like it. I know
this is going to be hard, so we will move slowly, in a step-by-
step manner. Secondly, we will look more closely at some of
the things you say to yourself, and test out whether these are
helpful, realistic, and true."
Behavioural Techniques
The behavioural component of CBT targets unhelpful behaviours

that maintain the problem.
Behavioural Activation
As explained in Box 4, the lethargy cycle is broken by encouraging

the patient to schedule and engage in meaningful activities. The
patient is told to do them “even if you don’t feel like it”. Activities
suitable for behavioural activation are those that increase positive
emotions like pleasure, satisfaction, and mastery. Examples include
exercising, social activities, previous hobbies, or even mundane tasks
(such as paying bills and doing the laundry) that when completed,
will bring about a sense of achievement.
Some guidelines for behavioural activation include:

1. Start small. Breaking tasks down into smaller steps makes
them seem easier and more achievable.
• Start with doing a 10-minute walk every day, or start
with tidying just one part of the room (e.g. throwing
dirty laundry into the laundry bin).
2. Be specific and schedule it into the calendar. Patients are

more likely to do it if they have planned for it.
• Specify the activity as much as possible (e.g. what, how
long, when, where).
• Engage the patient in this process by asking (rather than
telling) the patient what to do (“When will you do it?”).
• I will go for a 10-minute walk to the nearest supermarket
every evening before dinner.
98 Chapter 4
3. Anticipate barriers.
• Discuss what negative thoughts might get in the way
(e.g. “I’m not going to enjoy this”, “This is going to fail again”)
and come up with coping statements to overcome them.
4. For resistant or sceptical patients, this can be framed as

an experiment (“Try it out and see what happens to your
mood”).
Graded Exposure
In exposure, the patient faces his fears, usually in a gradual manner,

and learns that 1) he can cope with it, and 2) the consequences
might not be as bad as expected. E.g. someone with social anxiety
might be asked to approach someone at the store for help; or
someone who avoids crowded places due to a fear of experiencing
panic attacks might be asked to start going out to nearby places
and work towards going to crowded places during peak hours.
The aim is for the patient to experience a moderate level of anxiety,

but to stay in the situation instead of escaping. Through this, the
patient learns that his anxiety level peaks and drops if he stays
long enough in the situation (instead of spiralling out of control
which is what patients usually expect); in other words, the patient
habituates to it.
A graded approach to exposure is recommended, in which mildly-

feared stimuli are targeted first, followed by more strongly-feared
stimuli. This approach involves constructing an exposure hierarchy
in which feared stimuli are ranked according to their anticipated fear
reaction (like steps in a ladder). Generally, higher-level exposures
are not attempted until the patient’s fear subsides for the lower-
level exposure.
Graded exposure can be carried out in the following steps:
1. Present the rationale for exposure.

• A metaphor can be used to illustrate this. “Imagine you
were going to teach a child how to swim. This child is
afraid of the water. What would you do?” Patients are
usually able to say that they would first let the child sit
by the pool, then take him knee-deep into the water,
and gradually progress to dipping his entire body and
head in the water. The patient can also be asked to
consider what would happen if the child was allowed to
come out of the water every time he got afraid.
• Parallels are then drawn to the patient’s situation and
problem.
2. Create an exposure hierarchy (or ladder). An example is

shown in Table 3.
• Introduce the patient to the term Subjective Units of
Distress (SUDS), a way to rate anxiety from 0 (very
relaxed) to 100 (extremely anxious).
• Elicit the most anxiety provoking situation (highest level;
SUDS = 100).
• Ask the patient what would constitute an activity that
brings about a SUDS level of 50. This will be the first step.
• Brainstorm and list other activities between the first and
last step.
• Emphasise that these can be changed later on to make
it easier or harder.
3. Start from the first step. Prepare the patient by specifying

the task, planning for it, anticipating barriers, and discussing
ways to cope (much like in behavioural activation).
100 Chapter 4
4. Patient to do exposure on his own.
5. Patient returns and debrief is conducted. Difficulties will

be discussed. The therapist encourages the patient to
reflect on what he has learnt from the exercise.
TABLE 3 - SAMPLE EXPOSURE HIERARCHY

for Emily, who avoids taking public transport as she fears that a panic attack
might come on and she will not be able to cope.
SUDS
Steps Task Description
Level
1 Take the train one stop down 50
2 Take the train to the gym (3 stops down, 7-minute ride) 60
3 Take the bus to the library (20-minute ride) 70
4 Take the train to best friend’s house (20-minute ride) 80
Take the train to/from work during non-peak hour
5 85
(30-minute ride)
Take the bus to/from work during non-peak hour
6 90
(30-minute ride)
Take the train to/from work during peak hour
7 95
(30-minute ride)
8 Take the bus to/from work during peak hour (45-minute ride) 100
How are Cognitive Interventions Carried Out?

Cognitive interventions target maladaptive thoughts, beliefs and
assumptions held by the patient, and attempt to replace them with
more balanced and adaptive beliefs. The use of socratic questioning
is crucial here. Thoughts are framed as hypotheses, rather than
truths, and the patient is encouraged to test these hypotheses to
evaluate their validity. The process consists of the following steps:
1. Identify the thought or belief.

2. Apply cognitive techniques to test the thought or belief.
3. Encourage the patient to generate an alternative, more
balanced thought or belief.
Identifying Thoughts
In order to work with thoughts, we first need to recognise the

thought. Hence, the first step in cognitive therapy is for the patient
to identify and verbalise the thought. The easiest and most common
method is to ask the patient during the session, “What was going
through your mind?”, or “What were you saying to yourself?” The
patient can also record his thoughts in a thought diary outside of
session. A sample template of a thought diary can be found in the
Appendix. When patients are unable to verbalise these thoughts,
the doctor can aid the process by suggesting or guessing what
might be going on for the patient:
e.g. “Were you thinking that no woman would ever be

interested in you?”
“Were you thinking that your boss would think you are
incompetent if you asked for more time?”
Cognitive Distortions and Thinking Errors
As cognitive distortions and unhelpful thinking styles can perpetuate

the problem, it is important to teach patients to recognise them.
This can be done by providing them with a list of common thinking
errors (see Table 1) and having a discussion about which ones sound
familiar to the patient.
102 Chapter 4
The patient can then start to identify the types of thinking errors in
their thought records (see sample in Appendix), and ask themselves
some questions to test these thoughts. E.g. Someone who thinks
“It’s my fault, I never do anything right” is using ultimatums and
blaming himself. This person can be encouraged to ask himself
“Have there been other times when I have done well or other people
have complimented me?” or “Am I claiming responsibility for things that
are not within my control?”
A list of such questions can be found in Box 6 and Table 2.
BOX 6 - EXAMPLES OF QUESTIONS PATIENTS CAN ASK

THEMSELVES IN RESPONSE TO THINKING ERRORS
• What would I say to a friend or loved one in the same

situation?
• What would I say if this happened to a friend or loved one?
• What’s the worst that will happen? How could I deal with it?
• What’s the likelihood that the worst will happen? What
else might happen instead?
• Has a similar situation happened before? How did it turn out?
• Based on what I know from past experience, what is the
evidence that this will (or will not) happen?
• How does thinking this way help me?
• What are some other ways to look at this issue?
Alternative Explanations
The patient can be asked, “Could there be an alternative explanation

for what happened?”
John: He must’ve thought that having dinner with me would be
boring, so he cancelled the appointment.
Doctor: Could there be an alternative explanation for why he
cancelled the dinner?
John: I don’t know. Maybe something else cropped up. I know work
has been hectic for him.
Examining the Evidence
The patient is asked to imagine himself as a detective and through a

series of socratic questions, he searches for evidence for and against
an automatic thought or belief. An example is shown in Box 7.
BOX 7 - EXAMPLE OF A THERAPIST EXAMINING THE

EVIDENCE WITH JOHN
John: “He must have thought having dinner with me would be boring,
so he did not turn up.”
Doctor: “You think he cancelled on you because he didn’t think it was

worth meeting you.’
John: “Yes, I’m a boring person to be with.”
Doctor: “That’s an interesting thought, John. Let’s examine it a little

more. What is the evidence to support that thought?”
John: “Well, my ex-girlfriend said it when we broke up.”
Doctor: (takes out a piece of paper) “Ok, let’s put it here. What other
evidence do you have?”
104 Chapter 4
John: “I’m quite a quiet person. I don’t say much when I’m with people.”
Doctor: “Ok, what else?”
John: “Nothing else I can think of.”
Doctor: “Ok, now let’s look at the other side of the table. I wonder if
there is any evidence to show that you are not a boring person
to be with?”
John: “Not that I can think of.”
Doctor: “Has anyone ever said they enjoy your company?”
John: “I guess so. My nephew loves to play with me when he comes

over. Yeah, I guess he wouldn’t think I’m boring.”
Doctor: “Ok, let’s put that down. Any other evidence?”
John: “Well, I have other friends who have been trying to get me out,
saying they miss me, but I haven’t had the mood to meet them.”
Doctor: “And what does that mean - when they say they miss you and
want to meet you?”
John: “I guess it means I’m not that boring after all - there are at least
a few people who do enjoy my company.”
Thought: I'm a boring person to be with

Evidence for this thought Evidence against this thought
Girlfriend said this. Nephew loves to play with me.

I'm quiet and don't talk much. Friends miss me and want to meet me.
Pie Chart
The pie chart is particularly useful for patients who tend to assume
personal responsibility for things. The biased thought is identified,
and the patient is asked to list all alternative explanations that may
have contributed to the event happening. He or she is then asked
to assign a level of importance (out of 100%) to each of these
explanations on the list. Finally, he or she assigns the remaining
percentage to the original thought. This is drawn out in a pie chart
(see Box 8).
BOX 8 - EXAMPLE OF EMILY'S PIE CHART
Thought/belief: "My son failed his recent test because I wasn’t there to
revise with him the night before. It’s all my fault."
List all possible reasons and rate contribution:
a. My son did not start studying for it earlier despite my reminders (45%)
b. The test was hard (20%)
c. Unlucky - the topics he put more focus on did not come out (10%)
d. He was still recovering from the flu that day (10%)
Contribution of original thought (e):

e
100 - (45+20+10+10) = 15%
d
a New balanced thought: "He might have
done better if I had revised with him the
c night before, but this was only one of the
many reasons why he did not do well. It’s
b not entirely because of me."
106 Chapter 4
This exercise encourages patients to consider other reasons for the

occurrence of an undesirable event and through this, realise that their
role in it is actually smaller than what they had originally perceived
it to be. An alternative, more balanced, thought is then constructed.
For some patients who continue to place an unrealistic proportion
of blame on themselves relative to other factors, further socratic
questioning can be used to examine and test these beliefs.
Behavioural Experiments
Behavioural experiments are exercises in which information is
gathered to test the validity of the one’s beliefs. Both the doctor and
patient can take on a curious approach, and the exercise is framed in
a way that there is no loss to the patient for trying it out i.e. if it goes
as expected, the patient’s beliefs can be confirmed, but if it turns out
to be different, new beliefs can be constructed.
The following steps can be used:

1. The patient’s belief is expressed in the form of a statement, which
is the hypothesis to be tested.
• "If I stumble on my words in a presentation, people will notice and
laugh at me."
2. An experiment is designed to test out this belief.

• Stumble on a word during a presentation or meeting on purpose.
Get a trusted colleague to record how many people laugh. Later, ask
colleagues if they noticed me stumbling on the word.
3. The patient carries out the experiment, collects data, and records
the outcome.
4. A conclusion is made from the experiment. The patient discusses

with the therapist what this means for the original belief. An alter-
native, more adaptive, belief is constructed.
• "If I stumble on my words in a presentation, most people will not
notice. Those who notice tend not to laugh."
APPENDIX A
ABC Thought Diary
A
Describe the event
or situation leading
ctivating to unpleasant
feelings.
Event
B
What thoughts
were going through
your mind?
elief
How did you feel?
C
Name the emotion,
including any
onsequence physical sensations.
(Emotions)
What did you
C
do? Describe
your actions and
onsequence behaviour.
(Behaviours)
108 Chapter 4
APPENDIX B
Thought Diary: Thoughts As Hypotheses, Not Truths

A- Activating Event
Describe the event or situation, leading to unpleasant feelings.
B- Belief
What thoughts were going through your mind? Choose the “hottest” thought.
C- Consequences
Describe physical sensations, label emotions, and describe your behaviours.
D- Disputation
1. Am I making any thinking errors?
2. What is the evidence for/against this thought?
3. Has this situation happened before? What was the outcome?
4. What would I say to a friend or loved one who was having this thought?
5. What is the worst that could happen? How would I cope?
E- Energise
What is an alternative way of thinking?
What is a more realistic outcome?
What should I do?
1. Cognitive behavioural therapy looks at changing unhelpful

thoughts and behaviours that contribute to emotional
problems.
2. One’s perception and interpretation of an event determines
how one feels about the event.
3. A CBT formulation helps the doctor understand the factors
that maintain the problem and which areas to target in
treatment.
4. As CBT is collaborative in nature, the doctor shares the
formulation with the patient and provides psychoeducation
on the problem and its maintaining factors.
5. Socratic questioning is used to guide discovery, rather than
debating and persuading.
6. Both behavioural and cognitive techniques are employed in
CBT to change biased thoughts and unhelpful behaviours,
and to replace them with more balanced thoughts and
helpful behaviours.
110
Chapter 5
Mindfulness and
Self-Compassion
112 Chapter 5
“ The moment one gives close

attention to anything, even
a blade of grass, it becomes
a mysterious, awesome,
indescribably magnificent world
in itself."
Henry Miller
F
rom previous consults, Dr Quek knew that Amy tended to
be highly strung and anxious. However, despite repeated
exploration, Amy was unable to identify what made her so
tense. All she knew was that she was extremely anxious and that
this anxiety made her physically uncomfortable. She also felt
that she was a “loser” and a “weakling” for experiencing anxiety.
Despite such suffering, Amy refused to take any medication that
Dr Quek wished to prescribe for her condition. Dr Quek offered
to coach Amy in some mindfulness and self-compassion skills, so
that Amy had some way to manage herself whenever her anxiety
became too distressing.
Mindfulness in Context
Family doctors would sometimes encounter patients whom they

sense require more than medical interventions. These patients
usually present with acute but intense emotional responses.
Some of these patients would be able to verbalise their emotional
turmoil whilst others might express them more in terms of physical
Mindfulness & Self-Compassion 113
complaints such as insomnia, headaches, or indigestion. At other

times, it is the patients’ physical illnesses that are stress-provoking,
causing strong emotional responses that threaten to overwhelm
the patient. Intense emotional turmoil can have a debilitating effect
on physical health, regardless of whether they are the contributor
or result of physical symptoms. Furthermore, sufferers of chronic
physical illnesses would often report a sense of self-blame, negative
self-perception or reduced self-worth, which aggravates their
emotional turmoil.
Janet Christie-Seely (1995) argued that doctors not only take care of
the physical aspect of healing, they also take care of the emotional
aspects associated with physical wellness. Indeed, if the emotional
aspects of health and the emotional contributors to ill-health are
addressed, then it is likely that medical interventions would become
effective and enhanced. This is because the doctor is treating the
patient more holistically, not just addressing the physical aspects of
medicine, but also the emotional and mental aspects.
In the presence of patient emotional turmoil, interventions such

as mindfulness and self-compassion techniques might increase
the doctor's treatment repertoire. When explained and delivered
appropriately, mindfulness and self-compassion training can also
serve to empower the patient to do something about his or her
uncomfortable emotional and physical state.
Benefits of mindfulness
When we make the effort to be regularly and consistently

mindful, then we might experience several benefits. For instance,
114 Chapter 5
mindfulness-based therapy has been associated with reduction

of depression and anxiety symptoms, as well as those linked
to physical health problems. Participation in mindfulness-based
stress reduction training (a comprehensive mindfulness training
programme) is associated with reduction in stress symptoms,
ruminative thinking tendencies, and increased empathy and self-
compassion. Furthermore, mindfulness practices have been
related to improvement in functional somatic symptoms, immune
functioning, reduction in blood pressure and cortisol levels and
improvement in chronic pain experiences. Mindfulness brings
about these benefits because it enhances our capacity to relate
constructively to our physical and emotional differences – as
opposed to our usual symptom-perpetuating style of responding.
Benefits of self-compassion
Likewise, being compassionate towards ourselves and our

shortcomings has been shown to be beneficial. For instance,
being self-compassionate is associated with a reduced likelihood of
having a mental illness, an increased likelihood of being optimistic,
socially connected and psychologically well, and better physical
and mental health. Meredith Terry and Mark Leary (2011)
suggested that self-compassion could improve coping as well as
self-regulation, which in turn positively affects health-improving
behaviour and subsequently physical health status.
Before the doctor can coach patients in mindfulness and self-

compassion practices, he or she needs to understand what these
are both at a conceptual level and a personally experienced level.
So What is Mindfulness (And What is Not)?
Before you read on, take a moment to notice:

• The position of your body, and the sensations that go along
with this position – what are you aware of?
• The movement and sensations of your breathing as it moves
through your nose, down your chest and into your abdomen.
• The sensation of your hands as they hold this book – what
does the texture and weight of the book feel like?
• Any thoughts, images, impressions, emotions, memories or
even judgments about what you are doing now, come up in
your mind – allowing anything and everything to come up for
the moment.
• Any sounds happening around you at the moment – simply
noticing whatever sounds come to your awareness.
116 Chapter 5
How was this brief experience like for you? Was it in some way:
• A deliberate/ purposeful exercise of your attention? – You had
to make the conscious effort to pay attention to your body,
breathing, the book, your internal experiences and the sounds
surrounding you.
• Open and accepting? – You are allowing yourself to be aware of
all internal and external experiences without censoring anything.
• Free of judging or attempts to control any of these experiences? – You
are simply aware of everything, even any judgments or evaluations
about your awareness; and any urge control your experiences
• Happening in real time? – Your awareness of all of the
experiences above was concrete and as they were happening.
You were present in your body.
Congratulations and welcome! You have just had a brief taste of

being mindful. From your experience, mindfulness is simply:
"Purposefully acting to be aware of all of one’s internal and external
experiences happening in any moment, without any attempts to
change these experiences."
Now, think of a time earlier today or even several days before when you:
• Daydreamed during a meeting, an interaction or while doing
some other activity.
• Ate a meal without tasting it or remembering what you actually ate.
• Met a new person and instantaneously forgot his or her name.
• Heard what someone said to you and immediately forgot about
it.
• Got overwhelmed by upset or disgust or had some negative
emotion towards someone or something then tried to suppress
such negative emotions.

What was your state of mind during these moments? Was it in
some way:
• Dazed, forgetful, tranced-out and diffused – You were unaware
of the details of an experience?
• Conflictual and judgmental – You had some emotions and you
were being judgmental about these emotions? You felt as if
you were struggling against your own emotions?
• Out-of-body – You were somewhere else and definitely quite
unaware of your body?
• Automatic reaction – Your reactions tend to happen without
much deliberation or seemingly lack control?
How often have you felt like this? This state of mind is called
mindlessness, the opposite to being mindful. It is made up of
the automatic and almost knee-jerk reactions to situations and
our internal experiences. Mindlessness is characterised by being
absorbed into the mental narratives of the past and/or the future
with an underlying wish to avoid the unpleasant experiences. Often
this leads to the mistaken attempts at controlling what is outside
one’s sphere of control which only results in failure and further
frustration.
118 Chapter 5
How About Self-Compassion?
Self-compassion is another healthy response to our experiences.

It is the fraternal twin of mindfulness. Kristen Neff (2011) argued
that it involves having a kinder, more balanced relationship with
ourselves (our emotions, thought, actions, and experiences) in the
face of hardship or perceived shortcomings.
Think back to a time when you made mistake at work or in your

personal life. Were you:
• Highly critical toward yourself
– Beating yourself up about what you should have done or
could have done? Perhaps you even ran a story telling how
bad a person or doctor you are, going into detail the string of
catastrophes you just barely managed to avoid due to no fault
of yours.
• Feel like you are the only, single most inadequate person or
doctor in the world
– No one could make such a blunder as you? Surely competent
human beings or doctors do not make mistakes of this
magnitude?
• Become very caught-up with the idea of being unworthy
– This idea colours your day, and makes you recall every single
time you have made a mistake? Do you think along these
lines: “If I’ve made this mistake, then I must be a failure”?
This is self-hatred. It is the opposite of self-compassion. Now, think

back to a time when you made a mistake but (even for a little bit) you:
• Were kind to yourself
– You tell yourself that despite the mistake, you are still a
worthwhile human being. You show your emotions empathy,
much like you would show empathy to a friend in pain.
• Put things in perspective

– You are aware somehow that you are not the only person who
makes mistakes. Instead, you understand that being human
means we make mistakes, and that everyone has made a
mistake before. You are not alone in this.
• Were mindful
– You are able to relate to your emotions (even the critical ones)
at a comfortable distance. You are aware that there is a YOU
in which emotions are occurring, like clouds occurring in the
sky.
If you have managed this even for a little bit, then congratulations!
You were being self-compassionate. Kornfield (2008) put it this
way: you were in a place where “(your) love meets (your) pain”.
How are mindfulness and self-compassionate related? Put simply:
Self-Compassion Mindfulness
Open and • Deliberate
• Kindness to
accepting attention
yourself
relationship
• Common between • Non-judging, not
Humanity - self and attempting to
Everyone makes emotion change anything
mistakes. Everyone • In real time
is still worthy
120 Chapter 5
Some Ways of Being Mindful

Here are some simple exercises you and your patients can practice
on a regular basis to foster a more mindful living condition. Choose
the one that best fits you.
eEXE
EXERCISE 1: CURIOSITY
Curiosity is one part of the antidote to being overwhelmed by fear and

other strong emotions.
• Sit or stand comfortably upright, with your eyes looking downwards

and relaxed.
• Be aware of any experiences that are happening inside you right
now – they could be thoughts, images, emotions or sensations.
• Considering the flow of these experiences as a whole, can you
describe what it is like?
- Where do you feel this flow of experiences the most?
- What shapes or forms does it have?
- Does its shape change?
- What colours best describe this flow of experience?
- What are its movements like?
- Does it change with time?
- What other features does it have?
eEXE
EXERCISE 2: LABELLING
This exercise helps you be aware of experiences happening in real-time. It

also helps you have a more realistic and objective understanding of these
experiences. It helps create a distance between the person and his or her
experiences.
• Sit or stand comfortably upright, with your eyes looking downwards

and relaxed.
• Be aware of any experiences that are happening inside you right
now – they could be thoughts, images, emotions or sensations.
• Whenever you notice a prominent experience, mentally label it
“thinking”, or “feeling” or “sensations” or “images”.
• Keep labeling prominent experiences moment-by-moment.
• Do so for two to five minutes.
e
EXE
EXERCISE 3: BREATHING AS ANCHOR
This exercise is helpful for patients who need to stabilise their strong
emotions. It grounds the attention on something concrete (the breath),
bringing the person’s awareness out from the depths of their emotions
to their present physical reality. Note: the breathing is natural, and
there is no deliberate attempt to make it deep or slow.
• Sit or stand comfortably upright, with your eyes looking downward

and relaxed.
• Be aware of the natural rhythm of your breathing in your body.
• As you breathe in, mentally trace this breath in your mind. Silently
say: “Innnnnnn”, for the duration of this breath.
• As you breathe out, mentally trace this breath in your mind.
Silently say: “Ouuuuut”, for the duration of this breath.
• Leave everything else such as your thoughts, emotions,
sensations, impressions and memories in the background of your
awareness.
• Whenever your mind drifts to the background of your awareness,
gently bring it back to the current breath.
122 Chapter 5
eEXE
EXERCISE 4: MINDFUL ACTIONS
This exercise has the same effect as Exercise 3. However, it can be

applied more flexibly on-the-go. It is essentially turning all your routine
activities into mindfulness practices.
• Think of a task that you will be doing later. For instance, you might
be brushing your teeth.
• When you do brush your teeth, be aware of the physical action
and sensations of brushing your teeth.
• Make your actions deliberate, and also be curious about noticing
as many sensations as you can (both in your mouth, and in your
brushing arm).
• Be aware of the how these movements and sensations change as
you go about brushing your teeth.
• Repeatedly bring your awareness back to the motion and sensations
of brushing, leaving all other experiences in the background.
Here is another common activity most take for granted.

• As you walk from place to place, be aware of the movement of
your legs and feet. Also be curious about how your feet feel as
they contact the ground and then lift off from the ground.
• Notice the changes in movement and the sensations that follow as
you walk.
• Leave all other experiences in the background of your awareness,
always returning attention to your current foot-step.
The main principle for this exercise is to be fully aware of the motions
and sensations of your routine activity, while you leave all other
experiences in the background of your awareness. Choose some
activities that you do daily and plan to apply this principle to them.
You will get a lot of mindfulness practice that way!
e
EXE
EXERCISE 5: BEING AWARE OF THE URGE TO CHANGE
EXPERIENCES
While we can be aware that we should not attempt to change any of

our experiences, we will undoubtedly experience the urge to do so.
This exercise helps put things in perspective. It can also be used in
conjunction with any of the other exercises in this chapter.
• Whenever you encounter something you dislike.

• Whenever you encounter an experience you wish would be
different.
• Be aware of where you feel this desire to change your experiences.
• Take a moment to mentally and kindly say to this desire (in whatever
way you can imagine it): “Hi, it’s okay that you are here.” Repeat
this acknowledgement a few times if needed.
• Then return to the activity you were engaging in.
The principle here is to treat the desire to change experiences as

another experience in itself.
124 Chapter 5
Some Ways of Being Self-Compassionate

Here are some simple exercises you and your patients can practice
on a regular basis to develop greater self-compassion. Choose the
one that best fits you.
eEXE
EXERCISE 6: KIND WISHES
• Set aside two to five minutes.

• Sit comfortably upright with your eyes closed or looking at the
ground.
• Be aware of the natural movement of your breathing in your nose,
throat, chest or belly.
- When you breathe in, mentally wish yourself: “May I be well.”
- When you breathe out, mentally wish yourself: “May I be safe.”
- For the next in-breath, mentally wish yourself: “May I be loved.”
- For the next out-breath, mentally remind yourself: “I am worthy.”
• Repeat these four wishes, really meaning them to the best of your
ability, as you follow your breathing.
It might feel awkward initially, but you will likely feel more natural as you
continue this practice. This practice is particularly useful after a hard
day, an altercation or after you’ve made mistakes. Notice when you are
starting to beat yourself up after these incidents, and quickly respond
with positive wishes.
eEXE
EXERCISE 7: BALANCED SELF-TALK
On the topic of mistakes, we all make them. We make errors in the

tasks we do. We might treat other people badly. When you make such
mistakes, you might start giving yourself a hard time. At other times,
you might simply feel bad about yourself for some other reason. At
moments like this, take a moment to reflect in this manner:
A. Be aware and acknowledge your suffering

• Start by reflecting on this mistake or simply focusing on the
sense of feeling bad about yourself
- What emotions do you notice?
- What are you saying about yourself, in your mind?
• Mentally acknowledge these emotions by telling yourself
“There’s pain there.” Other variations include: “This hurts”,
“Ouch”, “It’s uncomfortable”.
• Mentally acknowledge the things you are saying about yourself.
– You could tell yourself “These thoughts are here.” (Other
variations include: “Yes, I’m thinking about myself in this way”).
B. Remember common humanity - everyone feels like this sometimes

• Next, reflect on how everyone feels like this sometimes – “I’m
not alone in feeling and thinking this way”, “Others feel this way
about themselves too”, “We all struggle in our lives”.
• You could also reflect like this: if it was a person dear to you
who feels and thinks this way, what would be a compassionate
response to them?
• Reflect about treating yourself with a similar compassionate
response.
• Finally, reflect on this: “Even though I have made a mistake/ feel
bad about myself for some reason, I’m still basically a worthy
person.”
Please note:
This exercise is NOT an excuse for the mistake! One still has
to acknowledge the mistake and make amends where possible.
Rather, it is about expanding awareness so that the practitioner
comes to appreciate that everyone feels similarly at some point
in their lives. It normalises the experience of self-blame and
suffering, and enables a more self-compassionate attitude. Self-
compassion is the first step towards making healthy amends.
126 Chapter 5
eEXE
EXERCISE 8: INNER RELATIONSHIP WORK
We are sometimes bombarded by negative self-talk and emotions. It is

as if we have a gremlin inside blaming us, criticising aspects of ourselves,
and whispering harsh judgments to us. These whispers can lead us to
dislike or even hate ourselves. Here is a more healthy way of treating
ourselves.
Whenever you notice self-criticism or negative feelings towards yourself.
• Be aware of where you feel it the most.

• Breathing in, gently say to the self-critical voice or negative
feelings (in your imagination): “You are here”.
• Breathing out, gently say to yourself: “I am here too.”
• Repeat this sequence to the natural rhythm of your breathing.
This exercise creates a kind of mental distance between your sense of

self and the emotions or thoughts that are floating within it. It reduces
the impact of these emotions and thoughts, by practicing a kind response
towards them. It is also a powerful mindfulness exercise.
e
EXE
EXERCISE 9: QUICK COMBINATION SELF-COMPASSION
While the first three exercises can be used independently, when

combined they can have a potent effect. We can do the combination
exercise at any time, regardless of whether we are experiencing negative
emotions towards ourselves or not.
A. Inner relationship: Take a moment to be aware of what emotions

and thoughts are floating around in your awareness. Gently and
kindly acknowledge them in some way.
B. Common humanity: For the self-critical thoughts and negative

emotions you carry, gently remind yourself that everyone struggles
with these feelings. You are not alone in this experience.
C. Kind wishes: Mentally wish yourself well.

• “Regardless of my feelings and thoughts.
• May I be well and may I be loved. I am worthy.”
e
EXE
EXERCISE 10: SITTING WITH SELF-CRITICISM
This is an adaptation from Paul Gilbert’s (2010) exercise for patients

who are overly self-critical. Self-criticism can heighten negative
emotions, and sometimes, people can become highly self-critical at
themselves for having negative emotions.
• Whenever you start to blame yourself or otherwise criticise

yourself in some way, take a moment to be aware of this critical
part and what it is saying about you.
• Next, with a gentle and soft breathing rhythm, start imagining a
compassionate person (this can be someone you really know or
simply imagine) who is treating you compassionately. This person
could simply be smiling at you or could be speaking well wishes to
you. Stay with this image, allowing more details of it to arise.
• Whenever you drift back to the self-critical part, imagine this
compassionate person also treating the self-critical part with
compassion.
• Then return to imagining the compassionate person treating you
with compassion. Repeat the last two steps as many times as
needed.
128 Chapter 5
An example of
COACHING MINDFULNESS & SELF-COMPASSION
A
Skills Coaching Protocol
Notice that Dr Quek uses the following protocol or steps to coach Amy:
STEP
1. Offer and explain why – Dr Quek offers the technique

and explains why and how it is useful. When offering
these interventions, start by explaining why and how
they can be useful.
• He relates the technique or practice to Amy’s
experience, making it relevant
Dr Quek: “Would you like to try something that can help with
your anxiety?”
Amy: [looks doubtful and a bit anxious] “I don’t know. Will it

really help?”
Dr Quek: “Well, I’m going to show you a non-medical method that

can decrease your anxiety. You’ve told me that your mind
is very active and this keeps the anxiety going. Is that
right?”
Amy: [replies] "Yes!"

Dr Quek: “You’ve also told me that you tend to be very critical

towards yourself when you feel anxious?”
Amy: [nods vigorously] “I just feel so useless! I can’t even

overcome something like this! It’s not like I’ve got cancer
or anything.”
Dr Quek: “Aha! You’re being harsh towards yourself right now!

So, this method will help you manage your anxious
mind, and also the harshness towards yourself."
Amy: [looks interested]
STEP
2. Demonstrate – Dr Quek proceeds to demonstrate the

technique. He uses simple language in his demonstration.
• Dr Quek has chosen to coach Amy using Exercise 9:
Quick Combination Self-compassion.
• Amy suffers from both intense anxiety and self-criticism
(“harshness”) so this practice is suitable for her.
• It is useful to provide a summary of the technique.
Dr Quek: “So this method has three steps you can do over and
over again, in sequence. Let me demonstrate. It is
usually done silently in your mind but I’ll talk you
through it out-loud.”
130 Chapter 5
Dr Quek: “So, I close my eyes and sit or stand upright comfortably.

I become aware of the natural rhythm of my breathing.
“Now, I’m aware of my anxious thoughts and also my

harshness. As I breathe in, I say to these thoughts
and harshness in my imagination, ‘You are here.’ As I
breathe out, I remind myself that, ‘I am here.’ I do this
for a few breaths.”
"Step 2, I remind myself as I breathe, ‘I am not alone

in experiencing this anxiety and this harshness. Other
people also have similar experiences.’”
“For the third step, I wish myself well. I might say

something like: ‘Even though I am anxious and have
harshness, may I be well and be loved. I am worthy.’”
“So I’ll summarise the three steps. First I become

aware of my emotions and I acknowledge them. Then
I remind myself that I am not alone in experiencing
these emotions. Next I wish myself well. I can repeat
these three steps as many times as I need.”
Amy: [when asked to try, she says] “I can’t remember the

steps.”
Dr Quek: “That’s alright. I’ll guide you. Later I’ll give you a
printout of the steps.”
Amy: [closes her eyes and listens to Dr Quek's instructions]

STEP
3. Patient practice – Dr Quek asks Amy to try the

technique, allowing her to have an experience of it.
• Notice that Dr Quek is correcting Amy as she goes along.
• Amy must try the technique. (It also allows Dr Quek
to correct any errors and Amy can raise her concerns
about the technique.
• Always check in with the patient about the
experience of the practice.
Dr Quek: “Now Amy, just be aware of the natural rhythm of your

breathing. No need to control your breathing, let it be
natural.”
“Now, be aware of your anxiety and harshness,

wherever these experiences are inside you. As you
breathe in, say to them ‘you are here’. As you breathe
out, say to yourself ‘I am here’. Do this for a few
breaths. Good.”
“Next Amy, as you breathe, remind yourself that ‘I

am not alone in experiencing these feelings. Other
people also have similar experiences.’ Again repeat
this mentally a few times. Good.”
“Now, as you continue breathing naturally, mentally

wish yourself well. Really mean your well wishes. ‘Even
though I have these feelings, may I be well and be loved.
I am worthy.’ Repeat this a few times.”
132 Chapter 5
Dr Quek: “Now Amy, do these three steps on your own a few more
times and continue for two more minutes.”
“Now you can slowly open your eyes. How was that for
you?”
Amy: [blinks a few times rapidly] “It was calming, but…”
Dr Quek: “Yes?”
Amy: "I don’t feel that I can wish myself well. It feels awkward.”
STEP
4. Clarification – Dr Quek answers any questions and

addresses any confusion Amy has about the technique.
• It would be good if possible to have a follow-
up consult to check how Amy is doing with the
technique.
Dr Quek: “Yes, I agree that it can feel awkward and artificial

initially but as you keep doing it, it will likely become
more natural. This part is very important as it reduces
your harshness towards yourself.”
Amy “Do I have to say these exact words?”
Dr Quek: “Nope. You can use any words for these three steps
as long as they are kind words and acknowledge your
experiences. You might want to come up with your own
phrases beforehand.”
Amy: “Ok.”
Dr Quek: “Here is a handout for you to remember the three steps.

If it’s ok, can I see you again sometime next week so that
I can check in with you on how you are doing with the
practice?”
Amy: [nods] “Sure.”
A
TIP
A WORD ABOUT ALL MINDFULNESS AND
SELF-COMPASSION EXERCISES
They have to be practiced regularly to have any benefits. They are

exactly like any physical conditioning exercises, which will only be
useful when done regularly and consistently. Another important
point is this: the benefits of these exercises are gradual and might
not be immediately noticeable. The physician is reminded to
explain this to the patient.
When are Mindfulness and Self-Compassionate

Practices Appropriate to Use?
Generally, mindfulness and self-compassion practices are beneficial

for most people. This is regardless of what medical or emotional
problems they have. They could be used during the consult with the
patient to calm them down if they are agitated. They also empower
patients between consults to manage their emotional turmoil.
However, there are some clinical conditions for which the doctor
needs to be cautious about recommending mindfulness or self-
compassion practices:
134 Chapter 5
1. Psychotic patients – it is best not to recommend these

practices for psychotic patients as they might further
aggravate the confused internal state of these patients. This
is because these practices require the patient to turn inwards
to be aware of their internal state, and to engage in different
internal responses. They effectively ask psychotic patients to
be aware of and come into close contact with their psychotic
states.
2. Anxious patients presenting with avoidance behaviours – this

constitutes a caution rather than a contraindication. Anxious
patients tend to engage in unhelpful avoidance behaviours
in their bid to quickly reduce the discomfort of their anxiety
symptoms. These behaviours provide immediate relief for
patients but perpetuate the anxiety in the long term. Hence,
the doctor needs to be mindful that mindfulness and self-
compassion practices are not used as avoidance behaviours.
A
TIP
SETTING EXPECTATIONS
It helps if the doctor explains at the outset when introducing the

practices that they are not meant to reduce emotional symptoms.
They are meant to help patients relate differently to these symptoms.
The doctor can further explain that any intention to use these
practices to improve symptoms would actually aggravate them, for
the expectation that they “work” or are “effective” would form an
additional stressor (e.g. the patient might say, “I’ve been noticing my
breathing for 20 minutes already, so why isn’t it working?”).
A
TIP
BEING MINDFUL WITH EXPECTATIONS
The doctor can also refer patients to Exercise 5: Being aware of the
urge to change experiences. The expectation that these practices
“work” is actually an urge by patients to change their emotional
experiences. The doctor could coach patients to practise Exercise 5.
Before You Teach... You Have to Practise
It is important for doctors to have some personal experience of some

mindfulness and self-compassion practices before they attempt to
coach patients in them. This is unlike medical procedures where
the doctor does not need to be on the receiving end.
By having some personal experience in mindfulness and self-

compassion, doctors can describe the experience of being mindful
and self-compassionate to patients, have an understanding of
the struggles of doing so, and have some familiarity with the
possible obstacles to practise that patients might encounter. This
not only allows them to coach these practices convincingly and
knowledgeably, it also allows them to be able to modify these
practices according to the patients' needs.
Finally, these practices are beneficial for the busy family doctor and
can reduce burnout. Do give some of the exercises above a try,
modifying them to suit your personal needs.
136 Chapter 5
1. Chronic physical health problems can result in emotional

turmoil, and emotional turmoil can aggravate physical
health problems.
2. Mindfulness and self-compassion practices are

beneficial for regulating emotional turmoil.
3. The basis of mindfulness and self-compassion is having

a direct, accepting and compassionate relationship with
all of one’s own experiences.
4. Discuss with your patient and select one or at most

two ways of mindfulness and self-compassion for him
or her to practise regularly.
5. Doctors should practise mindfulness and self-

compassion before attempting to coach patients in
these practices.
138
139
Chapter 6
Relaxation Techniques
140 Chapter 6
“ Nothing can bring

you peace but
yourself."
Ralph Waldo Emerson
M
r Tan is a 38-year-old man who was recently diagnosed
with hypertension. He felt stressed at work as there had
been a change in his reporting officer. This new officer
frequently sent him text messages and called him for updates. This
caused him much anxiety. His wife, although understanding, had to
deal with his irritability and occasional outbursts, leading to frequent
arguments. Mr Tan’s family doctor suggested that he may benefit
from relaxation interventions to reduce his stress symptoms.
How does relaxation help reduce stress?
“Fight or flight” is a term referring to the body’s stress response. It

is what the body does as it prepares to confront or avoid danger.
When appropriately invoked, the stress response helps us rise to
many challenges. But trouble starts when this response is constantly
provoked by less momentous day-to-day events, such as money
woes, traffic jams, job worries, or relationship problems.
Prolonged stress may result in health problems. A prime example is

high blood pressure, a major risk factor for heart disease. This is similar
to what Mr Tan is suffering from. The stress response suppresses
Relaxation Techniques 141
the immune system, thereby increasing susceptibility to colds and

other illnesses. Moreover, the build-up of stress can contribute to
anxiety and depression. We cannot avoid all sources of stress in our
lives (nor would we want to), but we can develop healthier ways of
responding to them. One way to invoke the relaxation response is
through a technique first developed in the 1970s at Harvard Medical
School by a cardiologist, Dr Herbert Benson. The relaxation response
is a state of profound rest that can be elicited in many ways.
The relaxation response is perhaps one of the most important skills

you can use to gain control over your body. Inducing a relaxation
response has broad health benefits, including the reduction of pain
and restoration of sleep.
In addition, research on the relaxation response has shown that this

simple technique can increase energy, decrease fatigue, as well as
increase arousal from a drowsy state. It can increase motivation,
productivity, and improve decision-making ability. The relaxation
response lowers both stress hormone levels and blood pressure.
142 Chapter 6
What is the Relaxation Response?
The relaxation response is defined as your personal ability to make

your body release chemicals and brain signals in order to make your
muscles and organs slow down and increases blood flow to your
brain. Drugs can do some of these for you; however, they often
have unwanted side effects. You can get your body to relax without
drugs while remaining conscious and aware at the same time. To
be physically relaxed and mentally alert is the goal of the relaxation
response.
The Relaxation Response is not:

• Laying on the couch
• Sleeping
• Not doing anything
The Relaxation Response is:

• A mentally active process that leaves the body relaxed
• Done in an awake state
• Trainable and more achievable with practise
There are many ways of achieving the relaxation response. Some of

these techniques are:
• Abdominal Breathing
• Counting Your Breath
• Progressive Muscle Relaxation
• Visual Imagery
Which is the best relaxation techniques?
To date, there is no data supporting the idea that one method is

better than another. What does matter is your willingness to use
a particular technique for your own health and your ability to gain
relaxation through that method.
The various relaxation exercises and their benefits are described

below. These relaxation exercises can be incorporated by family
doctors to teach their patients.
A) Abdominal Breathing
“Mr Tan, it sounds like your current day-to-day living involves a lot of
tension. I wonder whether you find yourself holding your breath at some
points, or breathing rapidly without realising it. The way that we breathe
has a very strong effect on our physical wellbeing because it encourages
a full oxygen exchange where we trade the incoming oxygen for outgoing
carbon dioxide. This deliberate method of breathing can slow the
heartbeat and lower or stabilise blood pressure, and also be a quick and
effective way of reducing our immediate stress. Would you be willing to
try and practise a simple deep breathing exercise?”
PURPOSE
Relax your body without the
use of drugs
GOAL
Concentrate on slow, deep
breathing and aid in disengaging
from distracting thoughts
and sensations
144 Chapter 6
STEPS:
1. Sit comfortably in the chair.
2. Place your hands over your belly button. The movement of
your hands will tell you if you are moving your abdomen as
you breathe.
3. When you breathe in, imagine the air flowing into your stomach
and filling it up. As you do that, allow your abdomen to rise up
away from your spine.
4. When you breathe out, imagine air flowing out of your
stomach like a balloon emptying itself. As you do that, allow
your abdomen to fall back towards your spine.
5. Now breathe this way, letting your abdomen rise and fall
without straining. Let your hands tell you if your abdomen is
rising and falling.
6. Breathe this way slowly and as you do it, say “In … out … in …
out” (repeat 10 to 20 times).
A
TIP
NOTE FOR ABDOMINAL BREATHING
When you have learned to relax using abdominal breathing, you

can use it to lower your tension level whenever you (i) anticipate
a stressful situation, (ii) experience a stressful situation, and
(iii) after the stressful situation ends. Most patients report that
abdominal breathing helps them get through difficult situations
more easily.
Not every patient will be able to do this unless you spend some
time coaching them to breathe using their diaphragm. If the
patient still cannot do it following coaching, it is better to use
another relaxation exercise.
B) Counting Your Breath
“Mr Tan, it is quite common for our minds to wander to many different
things such as our bodily sensations, noises, daydreams, plans, worries
and so forth, such that we find it difficult to be fully present at what
we are doing or to the person in front of us. When we can’t let go, we
cannot relax, leading to long term consequences on our physical and
emotional health.
Mindful breathing is a way to help you slow down your mind and
become more present, simply by observing your breathing. It helps you
to observe your experiences rather than react to them. As a result, it
can help you to calm your mind and relax your body. Would you like
to give it a go?”
PURPOSE
use of drugs
GOAL
To use breathing to increase
awareness, calm the mind,
relieve stress and relax
STEPS:
1. Sit comfortably in the chair.
2. Close your eyes or keep your eyes half-closed and gaze gently
at the ground in front of you. This helps to relax your eyes.
146 Chapter 6
3. Start by noticing your breathing. Some people notice it at

their nose as air moving in and out. Some people notice it as
movement in their chest or stomach. Pay attention to the part
that is most obvious.
4. Inhale and exhale slowly. Every time your exhale, count the
exhalation moving from 1 to 2 to 3 and so on.
5. Try to gently concentrate on your breathing.
6. Every time your mind wanders away and you forget to count
your breathing, just re-focus on your breathing and start
counting from 1 again.
ATIP
NOTE FOR "COUNTING YOUR BREATH"
This breathing exercise can be easier than the abdominal

breathing for some patients.
C) Progressive Muscle Relaxation (Tense & Relax Technique)
“Mr Tan, everyone’s muscles have their moments of tension and also
a baseline resting level. Some people have a great amount of tension
at rest, others less. When people are under acute stress, their muscles
tend to have higher levels of baseline resting tension that can be
painful and exhausting. Over time, they may forget how to let their
muscles relax. Progressive muscle relaxation is a way to achieve a
lower body relaxation. Through tensing and relaxing your muscles, the
tension level not only returns to the original level, but will automatically
drop below the original level, producing even greater relaxation to the
muscles. This can help induce the feelings of bodily muscle relaxation
that promote a sense of relief and rest.”
PURPOSE
use of drugs
GOAL
To tense and relax various
muscle groups of the body to
produce relaxation
STEPS for the Tense & Relax Exercise 1

(Preparation):
1. Make yourself as comfortable as possible in a seated position.
2. Try to sit up straight (with good posture) with your hands

resting on your lap.
3. You can keep your eyes open or shut. Most people prefer to
close their eyes. Remove your glasses if you wear them, some
people prefer to remove their contact lenses.
4. As you perform this exercise, you will tense different muscle

groups above their normal level of tension. When tensing, you
need not tense to the point of pain – simple tensing for two
seconds is generally sufficient. Focus on how the tension feels.
Then, let the tension go. Focus on the sensations of relaxation.
148 Chapter 6
5. Continue to breathe deeply and regularly throughout the exercise.
6. After you have become skilled at using this technique, you can
repeat parts of it in a shorter format when you need a quick
relaxation break. E.g. when sitting in a car during a traffic jam,
you can tense the muscles in your shoulders and upper back
and then relax them to get a nice burst of relaxation.
Let’s get ready to learn the tense and relax technique:
STEPS for the Tense & Relax Exercise II

(Tensing and Relaxing Specific Muscle Groups)
1. Relaxation of the feet and calves

• Flex your feet (pull toes toward the knees)
• Contract calf muscles and muscles of lower leg
• Feel the tension build up and hold the tension
• Take a deep breath
• As you exhale say the word “RELAX” and let the tension go
2. Relaxation of the knees and upper thighs

• Straighten your knees and squeeze your legs together
• Contract your thigh muscles and all the muscles of your legs
3. Relaxation of the hips and buttocks

• Tense the buttock muscles by squeezing them inward and
upward
4. Relaxation of the abdomen

• Observe your abdomen rising and falling with each breath
• Inhale and press your navel toward the spine then tense the
abdomen
5. Relaxation of the upper back

• Draw the shoulder blades together to the midline of the
body
• Contract the muscles across the upper back
6. Relaxation of the arms and palms of the hands

• Turn palms face down and make a tight fist in each hand
• Raise and stretch both arms with fists
150 Chapter 6
7. Relaxation of the chin, neck, and shoulders

• Drop your chin to your chest
• Draw your shoulders up towards your ears
8. Relaxation of the jaw and facial muscles

• Clench your teeth together
• Tense the muscles in the back of your jaw
• Turn the corners of your mouth into a tight smile
• Wrinkle the bridge of your nose and squeeze your eyes shut
• Tense all facial muscles in towards the centre of your face
9. Relaxation of the forehead

• Raise eyebrows upwards and tense the muscles across the
forehead and scalp
10. Intensification of relaxation throughout the body

• Focus on relaxation flowing
- From the crown of your head over your face down the
back of your neck and shoulders
- Down your body through your arms and hands
- Over your chest and abdomen
- Flowing through your hips and buttocks
- Into your thighs, your knees and calves
- And finally into your ankles and feet
• Continue to breathe deeply for several minutes
11. Finishing the tense & relax exercise

• Count backwards in your head from 3 to 1
• 3 – Become aware of your surroundings (location, people,
noises)
• 2 – Move your feet, legs, hands, arms, rotate your head
• 1 – Open your eyes feeling re-energised, refreshed, and
relaxed
A
TIP
NOTE FOR THE "TENSE & RELAX" EXERCISE
This strategy is useful for patients who experience stress as

increased physical tension or for those who tend to freeze and
stiffen when stressed. It is useful to demonstrate to patients how
to tense and relax each part of the body.
152 Chapter 6
D) Visual Imagery
“Mr Tan, some people find physical activities relaxing, while others
may be more relaxed through visual imagery, such as by imagining a
beautiful place. Visual imagery taps into the power of your mind to
not only distract yourself from pain, tension, or problems, but to also
increase images in your mind that are so captivating and rich in detail
that they produce feelings of relaxation, calmness, and peace. Would
you like to see if this is a technique you find useful?”
A
TIP
NOTE FOR VISUAL IMAGERY
This exercise is particularly useful for patients with very active

imagination. You may wish to test patients by asking them if they
tend to daydream or can see vivid images in their minds if they
wanted to.
Imagery is an acceptable way of obtaining the relaxation response,

but there are some guidelines on how to gain the most benefit
from this strategy.
How is visualisation carried out?

Start the exercise by sitting or lying in a comfortable position and
deep breathing. Unlike the tense-relax technique, the focus is not on
your body but on a pleasant image.
You will want to decide where you want to go in your image before
starting. Some people like to have several destinations in mind since
it may be difficult to stay interested in any one image for very long,
at least initially.
You can leave your eyes open or close. Most people prefer to close
their eyes when creating a mental image.
Your image can take you anywhere of your choice. It could be a

beach, a mountain retreat, a hiking trail, your own back yard, a fishing
pond, a clean kitchen with tasty cinnamon buns baking, a favourite
restaurant, a computer-generated virtual reality, or a psychedelic
‘60’s-like landscape. Whatever you choose, try to make it peaceful,
and calming.
In creating your image, try to USE ALL OF YOUR SENSES. E.g. if

imagining a forest or woods, try to imagine:
• Vision: the moss, trees, animals, sun, soil and leaves
• Smell: smell the moist earth, the heavy scent of green vegetation
• Sounds: hear the birds, sticks cracking, animals moving, creeks
• Feel: the cool moist air, cool soil, warm sun in a clearing
• Taste: the fresh water from a creek, a ripe berry, a sweet apple
Start off with five minutes then gradually expand your imagery time
to about 15-20 minutes per day.
This technique takes practice in order to fully master concentrating

on your image and not being distracted by internal bodily discomfort
or external noises. After you have become skilled at using this
technique, you can repeat parts of it in a shorter format (i.e. a few
seconds or a few minutes) when you need a quick relaxation break.
154 Chapter 6
Now let’s focus on the steps to relaxation through visualisation. •

•
PURPOSE •
•
Relax your body without the •
use of drugs
•
GOAL 2:
To use visualisation and
all your senses to produce
relaxation
Your imagery experience will have four parts: Entering the image,
the journey to a private place in the image, experiencing the private
place, and finally returning and ending the imagery.
STEPS for Visualisation
1: Enter Your Image

• As you enter your image notice the view.
• What is in the distance?
• What do you hear?
• Are there any immediate smells or tastes?
• Reach out and touch the things in your immediate environment.
• How do these things feel?
• What is under your feet? How does this feel?

• Are there any new smells or sounds?
• What is the temperature? Make it comfortable.
• Look above you. What do you see?
• What do you hear now?
• Identify a path along which you will travel as you journey
through this place.
2: The Journey
• As you begin your journey take several additional deep breaths.
• Your journey should take you deeper and deeper into your
image.
• As you travel, be keenly aware of the sights passing by you.
• As you travel, be aware of new sounds that occur.
• As you travel, be aware of the temperature, and feelings
under your feet.
• As you travel, be aware of the things you can touch and
examine their texture.
• As you travel, be aware of smells and tastes that enter your
image.
• Continue on your journey until you find a place of rich
sensory experiences. This is your private place.
156 Chapter 6
3: The Private Place

• Once you reach your private place take several additional
deep breaths.
• Your private place should make you feel calm, peaceful, and
filled with sensory pleasure.
• In your private place, be keenly aware of the sights around you.
• In your private place, be aware of new sounds that occur.
• In your private place, be aware of the temperature, and
feelings under your feet.
• In your private place, be aware of the things you can touch
and examine their texture.
• In your private place, be aware of smells and tastes that
enter your image.
• Stay in your private place for several minutes allowing your
imagination to run free with pleasurable images.
4: The Return Home

• Before you start to return home, notice how your body
feels. (You will want to return to this feeling in the future.)
• Try and recall the best aspects of your journey and of your
private place. (You will want to return to these in the future.)
• Prepare to leave by counting backwards from 3 to 1.
– 3 : Become aware of your surroundings (location, people,
noises).
– 2 : Move your feet, legs, hands, rotate your head.
– 1 : Open your eyes feeling re-energized, refreshed, and
relaxed.
Exercise:
As you prescribe relaxation technique(s) for Mr Tan, you may teach

him to use the table below to monitor and chart his own tension
levels daily, before and after the exercise to monitor his progress.
0 1 2 3 4 5 6 7 8 9 10
No Tension Extreme
Tension
Rate tension
levels Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Tension level
before
Progressive
Muscle
Relaxation
(3 days)
Tension level
after
Tension level
before
Visual imagery
(3 days)
Tension level
after
158 Chapter 6
Creating a Routine
You may also find the following tips helpful:
• Choose a special place where you can sit or lie down

comfortably and quietly.
• Don’t try too hard. That may just cause you to tense up.
• Don’t be too passive, either. The key to eliciting the relaxation
response lies in shifting your focus from stressors to deeper,
calmer rhythms. Having a focal point is essential.
• Try to practise once or twice a day, always at the same time, in
order to enhance the sense of ritual and establish a habit.
• Try to practise at least 10 – 20 minutes each day.
1. The relaxation response can significantly:

• Decrease pain
• Increase energy
• Decrease muscle tension
• Increase motivation
• Decrease irritability
• Improve sleep
• Enhance productivity
• Lower blood pressure
• Lower stress hormone levels
• Increase arousal from the drowsy state
• Improve decision-making ability
• Reduce fatigue
• Decrease anxiety
2. Over time, as patients use a relaxation exercise on a

daily basis, they can expect to get better at the skill.
160
Chapter 7
Behavioural Strategies for

Insomnia
162 Chapter 7
“ Adaywell-spent
brings happy
sleep."
Leonardo da Vinci
D
avid Sng had been suffering from insomnia for 10 years
since he started to work shifts at his job in the airport. He
tried various medications on and off for years, but had
not found significant relief for his sleep difficulties. The 35-year-
old bachelor recently changed jobs and now works office hours.
He often complained to his family doctor about difficulties falling
asleep and feeling that his sleep was too light. David’s difficulties
will be used to illustrate the concepts and strategies in this chapter.
What is the Prevalence of Sleep Difficulties?
Sleep is a quintessential part of human survival. Although its actual

function is still unclear, sleep deprivation studies have indicated
that sleep impacts on our memory and the restoration of our body
systems. Despite the importance of good sleep, sleep problems
continue to be prevalent and under-diagnosed in most societies
including Singapore and are often co-morbid with other physical
and mental health conditions. One Singapore study by Yeo
(1996) placed the prevalence of sleep problems in Singapore for
people aged between 15 and 55 years old to be 15.3%. A recent
Behavioural Strategies for Insomnia 163
newspaper article reporting on a world-wide survey suggested

that Singaporeans are the third most sleep-deprived people in the
world. Of the different types of sleep disorders, insomnia can
affect up to more than 30% of populations in developed countries.
Can the Family Doctor Effectively

Treat Insomnia?
Given that family doctors often serve as the first point of contact for
patients who are feeling unwell, they are well positioned to notice, treat
and triage patients with sleep difficulties. Often however, medication
is their choice of intervention whereas patients would prefer that their
doctor provide more of a supportive role, be more active in assessing
their unique needs and offer different treatment options.
These options include pharmacological, behavioural therapies or

a combination of therapies. Research has also demonstrated that
even brief behavioural interventions comprising 25-minute sessions
delivered twice a month in a primary care setting was sufficient to
improve sleep. This chapter provides family doctors with a set of
tools to quickly assess for sleep difficulties amongst their patients
A
TIP
DEFINITION OF INSOMNIA (DSM-V)
(Cunnington, Junge & Fernando, 2013)
Symptoms (can involve more than 1):

• Difficulties initiating sleep
• Difficulties staying asleep
• Adequate sleep duration that does not feel restorative
Duration: ≥ 4 weeks
Functioning: impacted daily functioning. Daytime sleepiness
experienced.
164 Chapter 7
and also serves as a guide on how to deliver brief behavioural sleep

interventions in their busy clinics.
What Are Some Common Causes of Insomnia?

Multiple factors contribute to insomnia and specific behavioural
interventions are designed to address these different factors. Factors
that can affect sleep can be broadly grouped into environmental
factors, lifestyle factors, psychological factors, physical factors and
routine factors.
These factors are summarised in the diagram below (Figure 1).
FACTORS THAT CONTRIBUTE TO POOR SLEEP
physical routine
 Inconsistent sleep-wake
environmental  Chronic pain timings across the days
 Too much clutter  Obstructive sleep  Lack of relaxing pre-sleep

apnoea routine
 Temperature too
 Physical over-arousal  Sleeping overly long
high or low
for various reasons (sometimes as an attempt
 Too much noise to make up for lost sleep)
psychological
lifestyle  Putting in too much effort to
sleep increasing arousal
 Too much caffeine or
caffeine intake <6 hrs  Strong emotions increasing
before bedtime arousal
 Overly long naps (>30 mins)  Mental over-arousal
eroding sleep drive  Clock watching when not sleeping
well increasing mental arousal
 Continuing to stay in bed when
unable to sleep
Overall, a lack of a consistent sleep-wake routine result in disruption

to one’s circadian rhythm. Over-compensating for poor sleep erodes
sleep drive required for deeper sleep. Other than these, mental and
emotional over-arousal also contributes to difficulties initiating sleep.
How is Assessment of Insomnia Carried Out?

Assessment of sleep difficulties typically involves identifying the
types of insomnia the patient is suffering from and also the aetiology
of these problems. A simple assessment worksheet can be found in
the Appendix at the end of this chapter.
Assessment worksheet for sleep difficulties and aetiology

Assessment is not only for the doctor to obtain clinically relevant
information. It also serves as an awareness-raising and educational
tool for patients.
Introducing the assessment to patient

“So David, as you are facing some difficulties sleeping, I’ve got a
simple questionnaire (refer to diagram below) here to help us figure
out the type of difficulties you have and find out what might cause
these difficulties. Let’s do this together.”
An example of
the questionnaire
that the doctor
can administer on
David to rate his
sleep quality
166 Chapter 7
A self-analysis INSTRUCTIONS
questionnaire that
allows the doctor 1. Tick the factors that feature in your life that affects
to determine the your sleep
type of behavioural
2. Choose the strategies that address the top few factors
strategies to use
on David NB: Mindfulness and relaxation are covered in the other
chapters of this book
Summarising the assessment findings and proposing interventions

“So to summarise, your sleep difficulties include difficulties falling
asleep, sleeping longer than necessary, and having no energy the
next day. Based on the questionnaire, some of the things that
might affect your sleep include some lifestyle, some psychological
and some routine factors. I’ve got a few techniques that can help
you deal with these things which might help you sleep better.”
What Behavioural Strategies Are There for

Treating Insomnia?
Some of the behavioural strategies to improve sleep are self-

explanatory and straight-forward, whereas others such as stimulus
control and sleep restriction are counter-intuitive and require patient
buy-in for effective execution. It is also important to remind patients
that these interventions need to be practised daily for two to three
weeks for new habit formation to occur.
A summary of various behavioural strategies is provided in the table

below.
Behavioural Strategies for Sleep
Strategy Description Best Used For

Relaxation Various mental or physical activities Physical and mental
that elicit the relaxation response. over-arousal; sleep
Patient are often advised to use initiation problems
these strategies to help with sleep
initiation or as part of their pre-sleep
relaxation routine
168 Chapter 7
Strategy Description Best Used For

Mindful- Exercises designed to help patients Strong emotions,
ness to accept their internal experiences mental over-
(e.g., emotions, thoughts) in a arousal; sleep
detached manner initiation problems
Sleep Education about how environmental, Addressing

Hygiene physical and habit factors can environmental
contribute to poor sleep. Involves factors,
discussing with patients on how to physiological and
change these in view of their current habit factors that
lifestyle affect sleep
Stimulus Conditions the patient’s mind and Conditioned

Control body to the sleep environment. wakefulness
Usually involves instructing patients
to go to bed only when they
experience sleepiness. Patients are
also advised to restrict the bed to
sleep and sex.
Sleep Involves reducing the amount of Poor quality

Restriction time spent in bed to approximate the of sleep, sleep
actual amount of sleep that patients that is too light;
naturally need. Often involves frequent night-time
starting with a much reduced sleep wakening
duration and slowly increasing this
duration across the weeks.
The following sections provide a more detailed explanation on how

to deliver each strategy. A possible educational script is also provided
for the doctors to explain the treatment rationale to their patients.
Relaxation and Mindfulness
Relaxation exercises and mindfulness are covered in other chapters

in this book. These are methods to address physical and mental
over-arousal which often affects sleep initiation. A possible way
of introducing relaxation and/or mindfulness to patients is as
follows:
“From the (assessment) worksheet, we can see that you try to

force yourself to sleep, you get frustrated when you cannot
sleep and your mind is very active. All these emotions and
mental activity make it challenging for you to sleep.
Relaxation exercises help to train our body to slow down

and switch off. Mindfulness exercises help us become less
bothered by strong emotions and thoughts which quiet the
mind. Let us try some of these now.”
Mindfulness and relaxation exercises can often be combined

together. For instance, abdominal breathing can be used as a
form of mental focus i.e. a two-step mindfulness exercise. If
time permits, it is useful to spend 10 minutes practising these
techniques with patients during your consult.
If there is insufficient time, provide patients with a list of CDs

or websites where they can listen to mindfulness and guided
relaxation audiovisual tracks. (Please see Appendix in Chapter 5
and 6 for a list of these resources available online).
170 Chapter 7
Sleep Hygiene
Sleep hygiene education often involves making practical changes

to the patients’ lifestyle, habits, environment and physical states.
A simple handout for patients can be found in the Appendix at the
end of this chapter.
“David, some of your lifestyle practices might also make it

more difficult for you to sleep at night. Currently you take
four cups of coffee to boost your energy in the day and also
nap on weekends to make up for lost sleep.
It may be tough for you to stop drinking coffee all at once.

How about if you start by reducing to two cups and stopping
by around 3 pm?
Also, you currently nap for two hours on weekends. Try

not to nap more than 30 minutes during the day because it
makes you more awake at night”
Although educating patients on sleep hygiene is often straight-

forward, challenges arise when patients are not ready to make
these changes for their own reasons. Common struggles for
patients include inability or lacking motivation to reduce substance
intake such as caffeine, alcohol or cigarettes. Other patients would
reject the idea of using eye masks or ear plugs because they feel
uncomfortable.
In these instances, the doctor needs to think of creative ways to

address these factors which patients are more receptive. Examples
of creatively working around patients who are not very receptive
include suggesting double-layered curtains that occlude light
maximally in place of eye masks, use of “door snakes” to occlude
noise coming from the gap under the door for people who are
averse to using the ear plugs etc.
Stimulus Control
Stimulus control is based on the idea that repeated pairing

between a stimulus and an internal state can result in a conditioned
response where the stimulus will automatically trigger that internal
state. For sleep, most people who struggle to sleep would force
themselves to stay in bed and try hard to sleep only to become
frustrated and mentally over-aroused. With repeated pairings
between the bed and feelings of frustration, the bed will come to
automatically trigger wakefulness and frustration instead of sleep
(i.e. BED = FRUSTRATION + WAKEFULNESS).
Stimulus control generally involves advising patients to go to bed

only when they are very sleepy and to get out of bed when they
are awake, when they start to struggle with sleep or when they are
doing non-sleep related activities (e.g. using the internet, eating,
talking on the phone etc.). With repeated disciplined pairings of
sleepiness with the bed, the bed will come to trigger sleepiness
and relaxation (i.e. BED = SLEEPINESS + RELAXATION). A simple
handout for patients can be found in the Appendix at the end of
this chapter.
“Like most people, you try to stay in bed and force yourself
to sleep when you are struggling to sleep. You told me that
you can spend up to two hours in bed before you fall asleep,
is that right?
When you become frustrated trying to sleep you become

more and more awake, and our bodies form a habit such
that every time you sleep in your bed or get into your bed,
you are automatically reminded of your frustration and
being awake.
172 Chapter 7
What you want for good sleep is for your bed to trigger
sleepiness when you lie down on it. So to do this, only go
to bed when you are very sleepy. If you start struggling to
sleep, get out of bed and do relaxation exercises until you
start falling asleep. Then go to bed again. Keep repeating
this because you want the bed to be constantly paired with
feeling very sleepy. Also restrict your bed to sleep and sex
only. What do you think? Is this do-able?”
Less intensive versions of stimulus control can involve the

following:
• Changing one’s sleep position and orientation
• Changing one’s bed, changing the bedsheets
• Changing the positioning of one’s bed
• Changing the sleep environment by removing or adding things
• Changing to another room to sleep
Less intensive stimulus control strategies work on the idea that

the bed-wakefulness pairing has not generalised to other possible
sleep environments. Often it is worthwhile introducing less
intensive strategies to patients who are not as receptive to the
standard stimulus control intervention.
Sleep Restriction
Sleep restriction intervention is often experienced as the most

intensive and intrusive intervention used to improve sleep. It is often
used to “reset” one’s sleep-wake pattern, to increase the depth of
sleep and to reduce frequent night-time wakening. The rationale
behind this intervention is that humans have limited sleep drive which
is often determined by the amount of melatonin that is secreted.
Excessive sleeping in the form of prolonged sleep beyond what one
needs or excessive daytime napping erodes and dilutes this limited

sleep drive. This in turn results in long, but very shallow sleep and
predisposes the person to be easily aroused by external stimulation
such as sound and light.
Sleep restriction typically involves advising patients to map their daily

sleep for two weeks and finding out the average time required and
then implementing the restricted sleep time based on this average
time. However, most patients would struggle to complete the sleep
monitoring. Doctors have therefore suggested five hours to be the
starting (and most restrictive) sleep duration. The steps for sleep
restriction are:
1. Determine the average sleep time required / using five

hours as the lowest limit.
2. Determine the time that the patient needs to wake up
(e.g. 6 am).
3. The restricted sleep time would be wake time – average
sleep time. If 5 hours is used, the sleep time would be 1
am (i.e. 1 am to 6 am).
4. Advise the patient to adhere to this sleep-wake time
strictly for one week on a daily basis.
5. In the second week, the sleep time is advanced by 30
minutes (i.e. 12.30 am to 6 am).
6. Every week, the sleep time is advanced by 30 minutes
until poor / light sleep starts to appear again. The sleep
duration in the week before poor / light sleep re-appears
is the optimal sleep duration.
A simple worksheet can be found in the Appendix at the end of this chapter
to help doctors and patients work out their sleep restriction duration.
174 Chapter 7
Explaining the sleep restriction rationale to patients is necessary

because of the intensity of the intervention. Here is a possible way
to explain it to patients (use handout on explaining sleep restriction
that can be found in the Appendix):
“So when you cannot sleep, like most people, you try to
sleep longer to make you feel more energised during the
day. However, this only makes your sleep very shallow and
you end up not feeling very rested. Am I right?
This is because all of us have limited sleep drive to spend

every day. This comes from how much melatonin our
bodies can produce. We need sleep drive to sleep deeply,
but when we sleep longer, we are diluting the sleep drive.
Sleep restriction is a powerful way to reset your body’s

sleep system and to maximize the use of your sleep drive
so that every hour you are asleep is as deep as possible.
Here is how we do it [Worksheet is presented to patient].”
“Here is how sleep restriction is done. It will require around

one month of daily effort to reset your sleep pattern. We
start of by setting what time you want to wake up, then
the sleep time is five hours before. We’ll keep to this sleep-
wake time for one week , then make the sleep time ½-hour
earlier in the second week and another ½-hour earlier
in the third and so on. Slowly, we’ll be able to find your
optimal sleep time that is not too long. Here’s a worksheet
to show how it is done”
“It is important to note that you will be more tired than

normal when you start the sleep restriction. It is useful to
rearrange meetings or important things to a later date if
possible.”
Putting Various Strategies Together

For the time-strapped family doctor, various sleep interventions
including stimulus control, sleep hygiene, relaxation and mindfulness
can be put together into a general handout for patients. See the
Appendix at the end of this chapter for the handout titled “Simple
Sleep Tips”.
176 Chapter 7
APPENDIX
Self-Analysis
A. What difficulties do you have? How often does it

A. Whathappen
difficulties
in a do you have? How often does it happen in a
week?
week?
 How often?
1. Problems getting to sleep
2. Waking up through the night
3. Waking up earlier than usual
4. Sleeping longer than is necessary
B. How good is your sleep?
0 10
Totally no Full of
energy the energy the
next day next day
APPENDIX
Self-Analysis
Instructions
1. Tick () the factors that feature in your
Z life that affects your sleep
Z
Z
2. Choose the strategies that address the
top few factors
NB: Mindfulness and relaxation are covered in other chapters in
this book.
178 Chapter 7
APPENDIX
Environmental Control
Make your room like a spa
• De-clutter your room, adjust the temperature, use
ear plugs / eye masks
• Use aromatherapy / light music
Lifestyle Control
• Reduce caffeine intake if possible; if not, restrict
caffeine to the mornings
• Try not to nap during the day; if needed, nap for no
longer than 30 mins as sleeping too long reduces
night-time sleep drive
Consistent Sleep-Wake Time

• Sleep is a bodily habit so set a consistent daily sleep
and wake time
• The sleep and wake time should not vary by more
than one hour on weekends
Physical Health Management

• Engage in aerobic exercise to deepen sleep
• Manage sleep apnoea by seeing an ENT specialist or
through postural changes
• Manage chronic pain through medication and
behavioural strategies
APPENDIX
Stimulus Control (BED = SLEEP + RELAXATION)
• Go to sleep only when

you feel sleepy. If you
are struggling in bed, get
out and do something
relaxing until you are
sleepy before going back
to bed
• Use your bed only for
sleeping and sex
• The goal is to pair up
sleepiness with the
bedroom so that your
bedroom will immediately
trigger a sense of
sleepiness
180 Chapter 7
APPENDIX
Sleep Restriction
• We have limited amount of sleep drive everyday

• Sleeping more means that you dilute your sleep drive and
every hour of sleep is light and shallow
• Napping during the day also uses up your sleep drive
• If you sleep less, you have more sleep drive for each hour
of sleep and your sleep will become deeper
APPENDIX
Sleep Restriction Worksheet
Sleep time = Wake time =

Current:
Duration =
Sleep time = *Wake time =

Week 1:
Duration = 5 hrs

Week 2:
Duration = 5.5 hrs

Week 3:
Duration = 6 hrs

Week 4:
Duration = 6.5 hrs
Important Note 1. It is important to remember that wake time stays the same. Sleep time
changes to be earlier with each week.
Important Note 2. Notice the week where sleep quality is affected. The sleep duration before
this week is the optimal sleep duration. For instance, if you start to struggle with 6.5hrs of
sleep, your optimal sleep duration is 6hrs.
182 Chapter 7
APPENDIX
ZZ
Simple Sleep Tips Z
1. Set up a wake time and stick to it daily.
2. Set up your sleep environment to hypnotise you to sleep. Make

it like a spa.
Dark, cool and spacious. Use lavender or other aromas. Put on soft ambient
music or sounds of waves or trees rustling in the wind. Use ear plugs and eye
shades.
3. Prepare your body to sleep starting from the afternoon

Stop caffeine before 3 pm. Power nap for 30 minutes maximum.
4. Set up and practise a relaxing pre-sleep routine

1 hour before bed, switch off your computer and T.V. read a book and have a
very light carbohydrate snack or warm glass of milk.
5. Go to bed only when you feel sleepy. Otherwise stay outside

and do something relaxing until you feel sleepy.
6. If you wake up at night and find it hard to go back to sleep, go

outside and do something relaxing until you are sleepy. Then go
to bed.
If you do these for 2 to 3 weeks, your sleep should improve

1. Brief behavioural sleep interventions can be effective

in primary care.
2. Sleep interventions are about new habit formation
and require patients to be consistent.
3. Factors that can affect sleep include environmental
factors, lifestyle factors, psychological factors,
physical factors and routine factors.
4. Different factors that disturb sleep require different
behavioural strategies.
184
References
186 References
Introduction:
1. Shea, S. C., & Maloney, M. (1998). Psychiatric Interviewing: The Art of

Understanding. 2nd Edition. W.B. Saunders.
2. Rogers, C., & Kramer, P. D. (1995). On Becoming a Person: A Therapist’s

View of Psychotherapy. Mariner Books.
3. Yalom, I. D., & Elkin. G. (1974). Every Day Gets a Little Closer: A Twice-
told Therapy. Reprint, 1991. Basic Books.
4. Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010).

The Heart and Soul of Change: Delivering What Works in Therapy.
2nd Edition. American Psychological Association.
Chapter 1:
5. Benbassat, J., & Baumal, R. (2004). What is empathy, and how can
it be promoted during clinical clerkships? Academic Medicine, 79(9),
832 – 839.
6. Christie-Seely, J. (1995). Counselling tips, techniques, and caveats.

Canadian Family Physician, 41, 817 - 825.
7. Feil, N., & Klerk-Rubin, V.D. (2012). The Validation Breakthrough:

Simple Techniques for Communicating with People with Alzheimer’s
and Other Dementias. (3e). Health Professions Press.
8. Halper, J. (2003). What is Clinical Empathy? Journal of General Internal

Medicine, 18, 670 – 674.
9. Hendricks, M.N. (2007). Focusing-oriented experiential psychotherapy:

how to do it. American Journal of Psychohterapy, 61(3), 271 – 284.
10. Hojat, M., Louis, D.Z., Markham, F.W., Wender, R., Rabinowitz, C.,
& Gonnella, J.S. (2011). Physicians’ empathy and clinical outcomes
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11. Jacobs, N., & Reupert, A. (2014). The effectiveness of supportive

counselling, based on Rogerian principles: a systematic review of
recent international and Australian research. Melbourne: PACFA.
12. Kim, S.S., Kaplowitz, S., & Johnston, M.V. (2004). The effects
of physician empathy on patient satisfaction and compliance.
Evaluation & The Health Professions, 27(3), 237 – 251. DOI:
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13. Meier, D.E., Back, A.L., & Morrison, R.S. (2001). The inner life of
physicians and care of the seriously ill. The Journal of The American
Medical Association, 286, 3007 – 3014.
14. Mesquita, B., & Albert, D. (2007). The cultural regulation of emotions.
In The Handbook of Emotion Regulation. Guilford Press.
15. Pollak, K.I., Alexander, S.C., Tulsky, J.A., Lyna, P., Coffman, C.J., Dolor,
R.J., Gulbrandsen, P., & Ostbye, T. (2011). Physician empathy and
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16. Poon, V.H.K. (1997). Short counselling techniques for busy family
doctors. Canadian Family Physician, 43, 705 – 713.
17. Ryan, R.M., La Guardia, J.G., Solky-Butzel, J., Chirkov, V., & Kim, Y.
(2005). On the interpersonal regulation of emotions: emotional reliance
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145 – 163.
18. Searight, H.R (2009). Realistic approaches to counselling in the office

setting. American Family Physician, 79(4), 277 – 284.
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Chapter 2:
19. Psychoeducation. Virtual Medical Centre. http://www.myvmc.com/

treatments/psychoeducation/ accessed 16 Dec 2015.
20. M.F. Tursi et al. (2013). Effectiveness of psychoeducation for

depression: a systematic review. Aust N Z Psychiatry, 47 (11): 1019-31.
21. T. Donker et al. (2009). Psychoeducation for depression, anxiety

and psychological distress: a meta-analysis. BMC Medicine 7:79.
doi:10.1186/1741-7015-7-79. http://www.biomedcentral.com/1741-
7015/7/79 accessed 16 Dec 2015.
22. J. D. Silverman, S. M. Kurtz, J. Draper. (1998). Calgary-Cambridge

Guide to the Medical Interview – Communication Process. Skills for
Communicating with Patients. Radcliffe Medical Press (Oxford).
Online Resources for Chapter 2:

• http://w w w.psychiatrictimes.com/ar ticles/psychoeducational-
resources
• http://dcf.psychiatr y.ufl.edu/resources/advocacy-organization-
resource-information/
• http://www.belmontwellness.com/for-mental-health-professionals/
psychoeducational-handouts-quizzes-group-activities/
• ht tps://w w w.nami.org /Learn-More/ Treatment /Psychosocial-
Treatments
• http://www.psychiatry.org/patients-families
• http://thrive.org.sg/index.php/home/know
Chapter 3:
23. Amrhein, P.C., Miller, W.R, Yahne, C.E., Palmer, M. & Fulcher,
L. (2003). Client Commitment Language during Motivational
Interviewing predicts drug use outcomes. Journal of Consulting &
Clinical Psychology, 71, 862 - 868.
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24. Amrhein, P.C., Miller, W.R, Yahne, C.E., Palmer, M. & Fulcher,
L. (2003). Client Commitment Language during Motivational
Interviewing predicts drug use outcomes. Journal of Consulting &
Clinical Psychology, 71, 862 - 868.
25. Miller, W.R. (1983). Motivational interviewing with problem drinkers.

Behavioural Psychotherapy, 11,147 - 172.
26. Miller, W.R., Benefield, R.G., & Tonigan, J.S. (1993). Enhancing
motivation for change in problem drinking: a controlled comparison
of two therapist styles. Journal of Consultant Clinical Psychology,
61 (3), 455 – 461.
27. Miller, W.R., & Rollnick, S. (1991, 2002). Motivational interviewing:

preparing people for change. New York: Guilford Press.
28. Miller, W.R., & Rollnick, S. (2013). Motivational interviewing: helping

people change. New York: Guilford Press.
29. Miller, W.R., Zweben, A., DiClemente, C.C., & Rychtarik, R.G. (1992).
Motivational enhancement therapy manual: a clinical research
guide for therapists treating individuals with alcohol abuse and
dependence. Rockville, MD: National Institute on Alcohol Abuse
and Alcoholism.
30. Nelson-Jones, R. (2006). Theory and Practice of Counselling and

Therapy. (4th Edition). London: SAGE Publication.
31. Rollnick, S., & Miller, W.R. (1995). What is motivational interviewing?
Behavioural and Cognitive Psychotherapy, 23, 325 - 334.
32. Sciacca, K. (2007). Dual Diagnosis Treatment and Motivational

Interviewing for Co-occurring Disorders. National Council
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33. Sobell, L. C., & Sobell, M. B. (2008). Motivational Interviewing

strategies and techniques: Rationales and examples. Retrieved from
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Chapter 4:
34. Westbrook, D., Kennerley, H., & Kirk, J. (2011). An Introduction to

Cognitive Behavioural Therapy: Skills and Applications (2nd Ed.).
Sage Publications: London.
35. Beck, J. S. (2011). Cognitive Behavioural Therapy: Basics and

Beyond (2nd Ed.). The Guilford Press: New York, NY.
36. Curwen, B., Palmer, S., Ruddell, P. (2000). Brief Cognitive Behaviour
Therapy. Brief Therapy Series. Sage Publications: London.
37. Miller, W.R., Benefield, R.G., & Tonigan, J.S. (1993). Enhancing
motivation for change in problem drinking: a controlled comparison
of two therapist styles. Journal of Consultant Clinical Psychology,
61 (3), 455 – 461.
38. Centre for Clinical Interventions Website: http://www.cci.health.

wa.gov.au/resources/index.cfm
(This website offers free resources and handouts that physicians
can print for their patients to supplement psychoeducation.)
Chapter 5:
39. Chiesa A, & Serretti A. (2009). Mindfulness-based stress reduction

for stress management in healthy people: a review and meta-
analysis. Journal of Alternative and Complimentary Medicine, 15(5),
593-600. DOI: 10.1089/acm.2008.0495.
40. Christie-Seely, J. (1995). Counselling tips, techniques, and caveats.

Canadian Family Physician, 41, 817 - 825.
41. Cornell, A.W. (2013). Focusing in Clinical Practice: The Essence of

Change. New York: W.W. Norton & Company inc.
42. Epstein, R.M. (2003). Mindful practice in action I: Technical

competence, evidence-based medicine, and relationship-centered
care. Families, Systems & Health, 21(1), 1 -9. DOI: 10.1037/
h0089494.
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43. Gilbert, P. (2010). The Compassionate Mind: How to use compassion

to develop happiness, self-acceptance and well-being. London:
Constable & Robinson Ltd.
44. Harris, R. (2008). The Happiness Trap: How to Stop Struggling and
Start Living. Boston: Trumpeter Books.
45. Hofmann, S.G., Sawyer, A.T., Witt, A.A., & Oh, D. (2010). The Effect
of Mindfulness-Based Therapy on Anxiety and Depression: A Meta-
Analytic Review. Journal of Consulting and Clinical Psychology,
78(2), 169 – 183. DOI: 10.1037/a0018555.
46. Holzel, B.K., Lazar, S.W., Gard, T., Schuman-Olivier, Z., Vago, D.R., &
Ott. U. (2012). How does mindfulness meditation work? Proposing
mechanisms of action from a conceptual and neural perspective.
Perspectives on Psychological Science, 6(6), 537 – 559. DOI:
10.1177/1745691611419671.
47. Kornfield, J. (2008). The Wise Heart: A Guide to the Universal

Teachings of Buddhist Psychology. New York: Bantam Books.
48. MacBeth, A., and Gumley, A. (2012) Exploring compassion: a

meta-analysisof the association between self-compassion and
psychopathology. Clinical Psychology Review, 32 (6), 545 - 552.
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49. Neff. K.D. (2011). Self-compassion, self-esteem, and well-being. Social

and Personality Psychology Compass, 5(1), 1 -12. DOI: 10.1111/j.1751-
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50. Raque-Bogdan, T.L., Ericson, S.K., Jackson, J., Martin, H.M., &
Bryan, N.A. (2011). Attachment and mental and physical health:
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51. Siegal, R.D. (2010). The Mindfulness Solution: Everyday Practices

For Everyday Problems. New York: The Guilford Press.
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regulation, and health. Self and identity, 10(3), 352 – 362. DOI:
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• Free Audio Tracks:
http://www.freemindfulness.org/download
http://marc.ucla.edu/body.cfm?id=22
• Books:
Jon Kabat-Zinn (2005). Wherever You Go, There You Are. Hachette
books.
Chade-Meng Tan (2014). Search Inside Yourself: The Unexpected
Path to Achieving Success, Happiness (and World Peace). HarperOne
• YouTube Videos:
https://www.youtube.com/watch?v=FnIjcLL25iA
Chapter 6:
53. Benson, H. (2000). The Relaxation Response, Bantam.
54. D.A. Williams & M. Carey. (2003).University of Michigan Health

System.
55. Heron, C. (1996). The Relaxation Therapy Manual, Winslow Press.
56. Davis, M., M’Kay, M., Eshelman, E.R. (2010). The Relaxation and
Stress Reduction Workbook. 6th ed. US: New Harbinger Inc.

• Free Audio Tracks:
https://www.mcgill.ca/counselling/self-help/audio-video
http://www.mckinley.illinois.edu/units/health_ed/relax_relaxation_
exercises.htm
http://w w w.the-guided-meditation-site.com/guided-imager y-
exercises.html
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Chapter 7:
57. Alattar, M., Harrington, J.J., Mitchell, C.M., & Sloane, P. (2007).
Sleep problems in primary care: A North Carolina family practice
research network (NC-FP-RN) study. Journal of The American
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58. Bootzin, R.R., & Perlis, M.L. (2011). Stimulus control therapy. In
Perlis., M., Aloia, M., & Kuhn, B. (eds.) Behavioral Treatments for
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59. Cunnington, D., Junge, M.F., & Fernando, A.T. (2013). Insomnia:
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consultations in primary care for sleep problems and insomnia: A
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city. The Straits Times, Saturday, 23 August 2014.
63. Lichstein, K.L., Taylor, D.J., McCrae, C.S., & Thomas, S.J. (2011).
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Singapore. Annals Academy of Medicine, 37(8)¸ 627 – 628.
65. Mansfield, D.R., Hillman, D.R., Antic, N.A., McEvoy, R.D., &
Rajaratnam, S.M.W. (2013). Sleep loss and sleep disorders: Shedding
light on common but under-recognised individual and community
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66. Morin, C.M., & Espie, C.A. (2004). Insomnia: A Clinical Guide to
Assessment and Treatment. NY: Springer.
67. Ong, J.C., & Manber, R. (2011). Mindfulness-based therapy for insomnia.
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for Sleep Disorders: A Comprehensive Primer of Behavioral Sleep
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M., & Kuhn, B. (eds.) Behavioral Treatments for Sleep Disorders: A
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About the Health Wellness Programme
H ealth Wellness Programme (HWP) is an initiative started in
2013 by Eastern Health Alliance (EHA). The aim is to support
Primary Healthcare Providers (PHPs) in their management of patients
with emotional and psychological conditions such as depression,
anxiety, adjustment issues, stress etc.
HWP is run by a group of mental health trained and clinically experienced

nurses and allied health professionals within the community. It is not a
psychiatric clinic, hence there will not be any diagnosis or medication
provided to the patients. Family doctors who refer their patients to
HWP continue to manage and provide medical treatment to them
while they undergo psychological therapy.
HWP offers the following services: -

• Supportive therapy for individuals, caregivers and family
• Understanding mental and psychological conditions
• Stress management and emotion management
• Lifestyle behaviour modification
• Expressive / creative arts therapy
Team Members of Health Wellness Programme (HWP)

Front Row From Left:
Yang Chek, Pan Huimin, Lim Hui Khim
Back Row From Left:
Janet Chang, Dr Tan Wee Hong, Dr Jean Cheng, Dr Tan Wee Chong,
Dr Andrew Peh

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Editor: Dr Andrew Peh

Medical knowledge changes constantly. As new medical research and

Copyright © 2016 by Eastern Health Alliance (EHA)

Dr Peh is a Senior Consultant in the

Ms Chang is a clinical psychologist

Dr Cheng completed her Masters in

Ms Pan is a Senior Occupational Therapist

Ms Lim is a Senior Mental Health

Dr Tan Wee Chong

Dr Tan is an Australian-registered clinical

Dr Tan is an Australian-registered clinical

Ms Yang Chek Salikin

Yang Chek has been in the nursing

The intended readership of this book is primary healthcare providers and

I am told that this book will be a companion information resource to the

In this book is the survival guide on techniques to promote behaviour

Associate Professor GOH Lee Gan

A/Prof Goh passionately believes that family doctors should develop to

We also wish to express our sincere thanks to Mr T K Udairam, Group

Special thanks go to Mr Ian Shen, Executive, and Ms Karen Kan, Senior

The description of the psychological interventions in this book has

• David Mee-Lee, M.D. (2005). Motivational Interviewing: Helping People Change.

References ................................................................................................................ 185

About the Health Wellness Programme ............................................................ 196

Making Every Consultation

Is prescribing patients just medication adequate?

psychological – which has a positive effect on health. It is believed

What has trust got to do with it?

How then does a doctor gain trust from a patient?

If the doctor is able to convey a warm attitude and sense of caring,

MAJOR GENERIC SKILLS

Does a patient with a psychological or emotional

In the book “Every Day Gets a Little Closer: A Twice-told Therapy”, Dr

It is said that of the total improvement a patient makes, only one-

So while techniques are helpful, a family doctor does not need

Where can a family doctor obtain training in

Counselling services may be readily available, but some patients may

“ The most precious gift

Why Should Busy Family Doctors Provide

Research has demonstrated that patients’ medical outcomes

More recently, Pollak and colleagues (2011) repeated these findings,

What Is Supportive Therapy?

Supportive therapy comprises two elements:

This can be incorporated into the regular medical clerking. It is

For instance, should a patient have been just diagnosed to have a

• What is the patient’s background and personality like?

and practice of physician empathy. Put in another way, empathy

A Simple Framework for Supportive Therapy

ASSESS, UNDERSTAND AND SUGGEST FRAMEWORK

What are some of these interactional skills?

ASSESS, UNDERSTAND AND SUGGEST FRAMEWORK

SUGGEST Options understand & Express

Examples of open-ended questions include:

The following question formats are useful:

Reflection of feelings involves the doctor saying back what he or she

The whole process is summarised as follows:

The following format can be used when reflecting the patient’s

Doctor: “You feel super stressed out. It’s all so overwhelming.

There are times when the

There are generally a few broad types of emotions:

• Sad – including any degree of low mood, unhappiness

If the doctor is unsure of the exact emotion to reflection, generic