Professional Documents
Culture Documents
Pressed
Pressed
Psychological
Interventions
In Primary Care
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.
ISBN 978-981-09-6566-2
Printed in Singapore
AuthorBiography
Dr Andrew Peh
[MBBS, M.Med (Psych), FAMS]
Psychiatrist, Changi General Hospital
Ms Janet Chang
[MPsych (Clin) (Melb); B.SocSci (Hons) (NUS)]
Clinical Psychologist, Changi General Hospital
Ms Pan Huimin
[B.Sci.Occ Therapy (La Trobe)]
Senior Occupational Therapist, Changi General Hospital
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
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.
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
Cognition T R U ST
Thoughts about the
doctor
Emotions
Feelings towards the
doctor
4 Introduction
GENUINE-
CARING COMPASSION
NESS
WARM
KINDNESS ATTITUDE
Making Every Consultation a Therapeutic Encounter 5
effectiveness substantially
by paying attention to the Extra-
therapeutic relationship. Therapeutic
Factors
TOTAL
TOTAL IMPROVEMENT
IMPROVEMENT
OF PATIENT
OF PATIENT
6 Introduction
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.
Making Every Consultation a Therapeutic Encounter 7
8
Chapter 1
Supportive Therapy
Key Points At A Glance
9
10 Chapter 1
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.
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.
Assess to
understand
central concerns
needs/goals/wishes
understand &
Suggest Express Empathy
options of the patient’s situation
& feelings
14 Chapter 1
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?”
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”.
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.
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.
Supportive Therapy 17
Doctor puts him or herself in the patient’s shoes to
understand the patient’s feelings
Doctor reflects the patient’s feelings
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!”
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.
Supportive Therapy 19
A
TIP
THE BASIC EMOTIONS
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.
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.
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.
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.”
The following are some conditions for which the doctor should not
use solely supportive therapy or may find it unsuitable:
Psychoeducation
30 Chapter 2
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
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”:
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: "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
APPENDIX
Factsheets on Depression, Anxiety and Adjustment Disorder
• 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
APPENDIX
Factsheets on Depression, Anxiety and Adjustment Disorder
Motivational Interviewing
42 Chapter 3
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.
y
QUOTE
MILLER AND ROLLNICK (1991)
COGNITIVE DISSONANCE
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
Motivational Interviewing 45
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
R eflections S ummaries
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.
Motivational Interviewing 49
A
TIP
HOW TO ASK OPEN-ENDED QUESTIONS
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
A
TIP
EXAMPLES OF AFFIRMING RESPONSES
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.
Motivational Interviewing 51
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
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
COMMITMENT
ACTIVATION
TAKING STEPS
A
NOTE
AMBIVALENCE
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
APPENDIX A-I
Other Complex Reflection Techniques:
In dealing with the patient's resistance, here are some strategies
using different reflection techniques:
APPENDIX A-II
APPENDIX A-III
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.
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.
“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?”
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?
• 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
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.
DESIRE
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."
REASON
APPENDIX C-III
NEED
COMMITMENT
APPENDIX D-I
4 Types of Resistance
(Source: Miller and Rollnick, 1991)
• 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.
APPENDIX D-II
APPENDIX E-I
Examples of "DEARS"
(Source: Sobell & Sobell, 2003)
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).
APPENDIX E-II
A
TIP
A SAMPLE OF DECISIONAL BALANCE WORKSHEET
APPENDIX E-III
BENEFITS/PROS COSTS/CONS
Making A
Change
Not Changing
II Expressing EMPATHY
APPENDIX E-IV
V Supporting SELF-EFFICACY
Cognitive
Behavioural Therapy
76 Chapter 4
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.
y
QUOTE
WILLIAM JAMES
Activating Event
Cognition (Interpretation)
What our minds say
Behaviour Emotion
What we do How we feel
Physiology
Bodily sensations experienced
Cognitive Behavioural Therapy 79
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
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”.
Cognitive Behavioural Therapy 81
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.
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
Cognitive Behavioural Therapy 83
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: 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
Maintaining Process
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.
Cognitive Behavioural Therapy 89
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.
Socratic Questioning
Emily: "I get so worried about making mistakes at work, that I spend so
much time checking and re-checking my work."
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: "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."
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."
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."
94 Chapter 4
Psychoeducation
Doctor: "John, you told me that you have been feeling quite down lately,
and as a result you have been staying at home more."
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: "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."
Cognitive Behavioural Therapy 97
Behavioural Techniques
Behavioural Activation
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.
Graded Exposure
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
Identifying Thoughts
“Were you thinking that your boss would think you are
incompetent if you asked for more time?”
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?”
Alternative Explanations
John: “He must have thought having dinner with me would be boring,
so he did not turn 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, 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.”
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.”
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).
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."
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%)
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
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.
3. The patient carries out the experiment, collects data, and records
the outcome.
APPENDIX A
A
Describe the event
or situation leading
ctivating to unpleasant
feelings.
Event
B
What thoughts
were going through
your mind?
elief
C
Name the emotion,
including any
onsequence physical sensations.
(Emotions)
C
do? Describe
your actions and
onsequence behaviour.
(Behaviours)
108 Chapter 4
APPENDIX B
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?
Cognitive Behavioural Therapy 109
Mindfulness and
Self-Compassion
112 Chapter 5
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
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.
Benefits of mindfulness
Benefits of self-compassion
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.
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
Mindfulness & Self-Compassion 117
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
• 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
eEXE
EXERCISE 1: CURIOSITY
eEXE
EXERCISE 2: LABELLING
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.
eEXE
EXERCISE 4: MINDFUL ACTIONS
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!
Mindfulness & Self-Compassion 123
e
EXE
EXERCISE 5: BEING AWARE OF THE URGE TO CHANGE
EXPERIENCES
eEXE
EXERCISE 6: KIND WISHES
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
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
e
EXE
EXERCISE 9: QUICK COMBINATION SELF-COMPASSION
e
EXE
EXERCISE 10: SITTING WITH SELF-CRITICISM
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
Dr Quek: “Would you like to try something that can help with
your anxiety?”
STEP
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: “That’s alright. I’ll guide you. Later I’ll give you a
printout of the steps.”
STEP
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?”
Dr Quek: “Yes?”
Amy: "I don’t feel that I can wish myself well. It feels awkward.”
STEP
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.”
Mindfulness & Self-Compassion 133
Amy: “Ok.”
A
TIP
A WORD ABOUT ALL MINDFULNESS AND
SELF-COMPASSION EXERCISES
However, there are some clinical conditions for which the doctor
needs to be cautious about recommending mindfulness or self-
compassion practices:
134 Chapter 5
A
TIP
SETTING EXPECTATIONS
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.
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
Chapter 6
Relaxation Techniques
140 Chapter 6
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.
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
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.
Relaxation Techniques 145
“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
Relax your body without the
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
ATIP
NOTE FOR "COUNTING YOUR BREATH"
“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.”
Relaxation Techniques 147
PURPOSE
Relax your body without the
use of drugs
GOAL
To tense and relax various
muscle groups of the body to
produce relaxation
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.
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.
A
TIP
NOTE FOR THE "TENSE & RELAX" EXERCISE
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
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.
Relaxation Techniques 153
You can leave your eyes open or close. Most people prefer to close
their eyes when creating a mental image.
Start off with five minutes then gradually expand your imagery time
to about 15-20 minutes per day.
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.
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
Exercise:
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
“ 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.
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.
A
TIP
DEFINITION OF INSOMNIA (DSM-V)
physical routine
Inconsistent sleep-wake
environmental Chronic pain timings across the days
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
Behavioural Strategies for Insomnia 165
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
Behavioural Strategies for Insomnia 167
Sleep Hygiene
Stimulus Control
“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?
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?”
Sleep Restriction
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
“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?
APPENDIX
Self-Analysis
How often?
0 10
Totally no Full of
energy the energy the
next day next day
Behavioural Strategies for Insomnia 177
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
APPENDIX
APPENDIX
Sleep Restriction
APPENDIX
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
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