PEACEFUL LIVING: INTERVENTION MANUAL COGNITIVE BEHAVIORAL TREATMENT FOR OLDER MEDICAL PATIENTS WITH GENERALIZED ANXIETY DISORDER, WITH OR WITHOUT DEPRESSION (Adapted from Stanley, Deifenbach, & Hopko, 2004; Wetherell, NIMH Grant # K23 MH 067643, 2005) Louise M. Quijano Jessica Calleo Julie L. Wetherell Melinda A. Stanley
when it is uncontrollable (can’t stop it once it starts) when it prevents you from accomplishing desired behaviors or life goals.” Use Workbook page 3 (My Experience of Anxiety) “Anxiety is comprised of 3 types of symptoms: physical (how the body reacts) -Have the patient check off and discuss their physical symptoms. thoughts (what’s going on in the mind, worries, concerns) -Have the patient check off and discuss their anxious thoughts. behaviors (actions that occur along with anxiety such as avoiding feared situations or doing something unhealthy or time consuming to reduce anxiety).” -Have the patient check off and discuss their anxious behaviors. Overview of Treatment Options “Anxiety, if not managed, can significantly interfere with a person’s behaviors, health and thoughts. There are two primary types of treatment that research supports as useful.” “The first form of treatment for anxiety involves teaching a how to better manage and understand anxiety. That is what we are offering in these meetings. Many professionals including psychologists, social workers, and mental health counselors can help people individually or in groups to develop new ways of coping with their anxiety. These types of counseling services are also useful for the treatment of depression.” “The second form of treatment for anxiety (and depression) is medication. Although we are not offering medication through this program, you may be prescribed medication by your PCP. If you would like to learn more about how to talk about this type of treatment with your doctor, we have worksheets available.” Handout Workbook page 4 (How To Reduce Anxiety) Discuss with the patient: “To increase your awareness of situations that create anxiety for you and increase your ability to notice symptoms of anxiety, we want you to record at least once per day some experience with anxiety. It doesn’t have to be overwhelming anxiety, but some kind of experience with even a slight increase in stress. The goal is to describe the situation and your feelings, noting any physical signs, thoughts or worries, and actions or behaviors that you don’t do (i.e., avoid) or those you do too much.”
1. Review Practice Exercises Briefly review Practice Exercise adherence, relaxation, calming statements and any previously learned coping tools/skills - practice again if necessary. Provide any necessary feedback and additional instruction. If patient did not complete practice exercises: Use motivational interviewing skills (Manual pages 9-10) and/or problem solve to determine the best way to accomplish practice exercises. Ask if they feel the practice exercises are worth the time it takes to complete them. Suicide Assessment. If pretreatment assessment indicated the presence of significant depression or suicidal ideation query the patient with regard to these symptoms. Follow the Suicidal Ideation Form (Appendix G). 2. Explain the purpose of Thought Stopping. Changing your Thoughts to Manage Anxiety II part 1 (thought stopping) and part 2 (cognitive restructuring) can be covered in different ways using your clinical judgment. The two parts of this module can be covered as follows: 1) Using part 1 (thought stopping) OR using part 2 (cognitive restructuring). 2) Using both part 1 (thought stopping) covered in a session and then using part 2 (cognitive restructuring) covered in the following 2 sessions. “The goal of the skill we are learning today is to stop dwelling on anxiety-related thoughts and images. Although everyone experiences some amount of worry at some points in their life, spending hours worrying can get in the way of you using calming skills or even completing fun activities. Do you find that worry ever interferes with your life?” “One strategy to reduce feelings of anxiety is to STOP the thoughts when they’re interfering in our life. The basic idea is to stop dwelling on anxiety-provoking thoughts and images through self-control.” “Thought stopping consists of two important parts: The first is to use anxiety-provoking thoughts and images as cues to stop ruminating. The second part is to immediately redirect your attention to relevant ongoing activities and your surroundings. For example, you can use an image such as a "big red stop sign" or a big pink eraser to stop dwelling on the thoughts and images, then quickly focus on what’s around you (such as what’s happening outside or the details your surroundings).
Week 1 Week 2 Week 3 Week 4 Week 5 Timeline Session 1 Follow-up Session 2 Follow-up Session 3 Follow-up Session 4 Follow-up Session 5 Follow-up Telephone or In-person Telephone In-person Telephone In-person or Telephone Telephone In-person or Telephone Telephone In-person or Telephone Telephone Time in Session 60-75 min 10 min 30-40 min 10 min 30-40 min 10 min 30-40 min 10 min 30-40 min 10 min Core Component Orientation & Motivational exercises Increasing Awareness Review monitoring Review Awareness Deep Breathing Review monitoring Review Deep Breathing Calming Self-Statements Decide on Elective Sessions Review monitoring Review Continuation or New session Review practice exercises Review Continuation or New session Review practice exercises Appendix B Treatment Session Outline
Week 6 Week 7 Week 8 Week 9 Week 10 Timeline Session 6 Follow-up Session 7 Follow-up Session 8 Follow-up Session 9 Follow-up Session 10 Telephone or In-person In-person or Telephone Telephone In-person or Telephone Telephone In-person or Telephone Telephone In-person or Telephone Telephone In-person Time in Session 30-40 min 10 min 30-40 min 10 min 30-40 min 10 min 30-40 min 10 min 30-40 min Core Component Review Continuation or New session Review practice exercises Review Continuation or New session Review practice exercises Review Continuation or New session Review practice exercises Review Continuation or New session Review practice exercises Review Maintenance plan Elective Skills: Sessions 4-9 Changing Your Behavior: For Depression Changing Your Behavior: For Anxiety Behaviors Problem-Solving Sleep Skills Changing Your Thoughts to Manage Anxiety II (Thought Stopping) Changing Your Thoughts to Manage Anxiety III (Cognitive Restructuring) Learn How to Relax II