Counseling Today, Online Exclusives

Bringing CBT into the doctor’s office

By Bethany Bray September 12, 2018

When you get your annual physical, does your primary care physician ask if you’ve been feeling atypically sad or anxious lately?

Primary care doctors are often the first professional a person will tell about symptoms related to depression or other mental health issues. With this in mind, two Pennsylvania counselors have created a presentation on coping skills and takeaways from cognitive behavior therapy (CBT) that medical doctors can use with their patients.

When Brandon Ballantyne and Kevin Ulsh spoke to the primary care physicians and other medical personnel at Tower Health in Reading, Pennsylvania, recently, they found an interested and engaged audience. The medical practitioners were particularly interested in learning more about how to help patients who present with anxiety and related problems during medical appointments.

Ulsh and Ballantyne are mental health therapists in the inpatient and partial hospitalization programs, respectively, at Reading Hospital, which is part of the Tower Health system. Ballantyne is also a licensed professional counselor and American Counseling Association member.

How can aspects of CBT be translated for use in the medical professions? CT Online asked Ulsh and Ballantyne some questions to find out more.

 

How did this come together? Did you reach out to the doctors, or did they invite you to come?

We have always been interested in the concept of extending coping skills practice and implementation into primary care settings. We believe that the primary care setting is where most individuals first report problems associated with anxiety, stress, depression and so on. In many situations, the primary care physician is the first provider to address such issues.

Recently, we have observed a growing trend to integrate primary care and behavioral health services. We decided to take these observations and build a coping skills lecture that can assist providers in the primary care setting with addressing stress and anxiety, along with other mood-related problems with the patients they serve. We developed an outline for a presentation and broadcast the idea to the primary care Tower Health continuing education team, who then gave us an invitation to present it as a part of their lecture series.

 

How did it go? Were the doctors open to your message? What were some of the things they asked or commented about?

The lecture went well. The doctors in attendance were attentive and interested. They asked several questions about how to address behaviors particularly associated with adolescent anxiety such as school avoidance and oppositional defiance. We addressed these questions by referring back to the cognitive model, which we highlighted as a foundation of our lecture.

We think it was important to have a discussion with the doctors about the clinical indicators of avoidance versus defiance. Utilizing a cognitive philosophy, we emphasized that avoidance typically shows itself as a behavior which prevents an individual from doing something that they would like to be able to do or would want to be able to do if not affected by anxiety. The anxiety that drives avoidance is typically a product of some anticipated fear. … The individual has cognitively come to the conclusion that the fear itself is an already established fact or guarantee.

Defiance, on the other hand, is a behavior that is driven by the desire to maintain control by resisting demands and expectations to comply with things that are simply undesirable. In other words, in the cognitive process that drives defiance, an individual may think, “If I don’t like it or don’t want to do it, then I don’t have to, and it doesn’t matter what anyone says.”

Therefore, primary care physicians may be able to get a better handle on what it going on with the patient, clinically, simply by asking about their thinking.

 

From your perspective, how could CBT be helpful in a medical setting? Please talk about why you chose to focus on CBT when you spoke to the doctors.

We chose to focus on cognitive behavior therapy when providing this lecture because CBT is an evidence-based approach that has been shown to be an effective form of treatment for multiple psychological problems across various populations. We believe that in the primary care settings, patients will benefit most from socialization to the cognitive model, so that they can gain a clear understanding of the difference between a thought and an emotion.

Once an individual understands the relationship between a thought, an emotion and a behavior, they acquire control over regulating their mood and reactions in a positive way. CBT-based skills are goal-oriented, problem-focused and able to be introduced and taught to individuals dealing with a wide range of psychological problems.

In the fast-paced primary care setting, brief psychological education and skills practice can be a piece of the treatment puzzle that not only addresses the emotional problems of the patient, but also offers skills that they can continue to utilize and benefit from outside of the office (such as deep breathing, sleep hygiene, behavioral activation, disputing cognitive distortions, thought journals, activity scheduling, etc.).

 

From your perspective, what are the benefits to this kind of collaboration? In other words, benefits not only for the professionals involved, but for the patients/clients too.

There are multiple benefits to this kind of collaboration. We believe that in most cases, the first call that patients make when they are not feeling well is to their family doctor. On some occasions, they are being seen by their family doctor for a physical health issue. However, in the midst of assessment, they may reveal an emotional problem or talk about a significant stressor that is causing psychological distress.

This is because for the most part, individuals attend treatment with a primary care doctor whom they trust. Maybe they have been seeing this doctor for most of their life. They have learned to confide in this doctor quite often. Therefore, they may be more open to acknowledging emotional problems within that office setting.

The type of collaboration that we facilitated reinforces the importance of integrating psychological education and coping skills practice into a primary care setting. For professionals, it improves the continuum of care and reduces the stigma of mental health problems. Ongoing behavioral health collaboration, and having a behavioral health component to primary care treatment, implies that psychological distress is a natural area of assessment which patients might otherwise be hesitant to acknowledge or discuss. In this way, patients can become more open to behavioral health support and more accepting of their need to seek outpatient therapy to further resolve symptoms.

 

What advice or tips would you give to counselors who might want to collaborate with medical professionals, like you did, in their local area?

We would suggest that mental health professionals in all parts of the country consider developing a presentation on one particular area of therapy and/or psychological education that you feel passionate about [and] which you also utilize with the clients you serve. The goal is to develop a component of that theoretical orientation that is applicable to a primary care setting. It has to be something that primary care physicians can utilize within the short amount of time that they have with their patients.

We found that in our lecture, doctors were most interested in the practical applications of CBT as it pertains to the acute management of anxiety. We assume that other helpful topics may be closely related to dialectical behavior therapy [and] concepts such as mindfulness, distress tolerance and opposite action.

 

Is this something you think that counselors could or should do more of? What did you learn through this process?

As a result of providing this lecture, we learned that primary care doctors are very much interested in behavioral health support and assistance. It seems as though there has been an increase of patients presenting to family physicians with emotional problems. The doctors that we spoke with were very thankful for the background on CBT and the skills practice that we provided. In fact, they practiced some of the skills with us.

It reminded us that regardless of the [health] profession, we all will be most effective [with] our patients if we are also taking good care of ourselves. Integrating behavioral health support, psychological education and coping skills practice into a primary care setting reinforces the importance of seamless multidimensional treatment, ultimately helping patients to receive effective care that addresses their physical and emotional needs, and offers the safety to accept the behavioral health treatment that they may otherwise be hesitant to pursue.

 

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Ballantyne and Ulsh can be contacted via email:

Brandon.Ballantyne@towerhealth.org

Kevin.Ulsh@towerhealth.org

 

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Related reading, from Counseling Today:

Integrated interventions

The counselor’s role in assessing and treating medical symptoms and diagnoses

When brain meets body

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

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