CBT Training Behind the Wall

Article Published in CBT Today Vol:41 Number 3 September 2013
October 3, 2013 at 11:48pm
CBT Training Behind the Wall

David Raines visited Ramallah last December to deliver an introductory course in cognitive behavioural therapy for mental healthprofessionals working for the Palestinian Counselling Centre (PCC). Here he talks about his visit and the issues facing CBT professionals in Palestine

For 30 years the PCC has struggled with limited resources to develop and improve mental health services in Palestine. They now have five departments providing individual and group therapy in Jerusalem, Ramallah, Nablus and other centres. My visit was organised by Sumud Palestine (Steadfast Palestine), a new charity raising funds to provide training and supervision for mental health professionals in the West Bank and Gaza.

Cognitive behaviour therapy is in the early stages of development in Palestine. Most of the PCC staff had read about and received some lectures on the theory of CBT but they have few opportunities for practical training and supervision in this evidence based therapy.They work in a challenging environment with a range of clients, many of whom have been traumatised by the on-going conflict between Palestine and Israel.

For four days I had the pleasure of introducing the theory and practice of CBT to an enthusiastic and enquiring group of mental health workers. Using case examples suggested by the organiser of my visit we examined and explored the assessment and treatment of Jamal, a 40 year old married man with four children who has suffered from depression since his employers closed their business because of the loss of trade caused by the Separation Wall, and Rama, a student at Birzeit University who had a panic attack whilst trapped in a crowded checkpoint and then developed agoraphobia.

Using standard CBT assessment techniques we explored Rana and Jamal’s problems and the relationship between what they experienced physically, their thoughts and emotions and how these had influenced their subsequent behaviour. We looked at how their problems started, How they developed and the impact on their daily life. We considered in detail what was happening before and after their problems occurred and discussed Rama and Jamal’s goals and ambitions.

I was intrigued by the students as they developed their role plays and six versions of Jamal and Rama emerged. In each I gained a privileged glimpse into the lives of ordinary Palestinians living in the
Occupied territories. Drawing on their own experiences or those of their families, friends and patients they developed the characters of Rana and Jamal. I cannot think of any way to gain a better insight into the impact of the on-going Israeli occupation of the West Bank and Gaza on ordinary Palestinians.

There were interesting discussions about the dissonance experienced by the therapist building hope for the future to combat depression in their patients while at times struggling to see a positive future for their country and themselves.

By the end of the second day the group had reviewed the assessment information Rana and Jamal had given us and developed a formulation that helped to explain onset and maintenance of their problems.
We finished by discussing how the students would counsel and support people experiencing similar problems.

During the last two days we reviewed a range of evidence based treatments familiar to every cognitive behaviour therapist (exposure, behavioural activation, cognitive restructuring and problem solving). We looked at how we might help Rana and Jamal to use these strategies. Together we tried to identify common elements of treatment where there were similarities between their present practice and the cognitive behavioural treatments I was introducing.

The students participated with interest and enthusiasm and the feedback was excellent but each recognised the need for on-going training and supervision. That’s where Sumud Palestine needs your help.

Sumud plan to build a network of experienced therapists prepared to give a little of their time to provide internet supervision to the Palestinian health workers who attended the introductory course.
Sumud is also seeking to recruit experienced trainers willing to journey to Ramallah in the West Bank to provide training as part of a modular CBT programme. Sumud will meet travel costs and other essential expenses.

I have little doubt that anyone suitably qualified and ready to give their time to
will be rewarded, as I was by the warmth and hospitality that Palestinians offer to all their visitors.


David Raines

Please email Sumud Palestine’s chair, Mohammed Mukhaimar
(mkm1975@hotmail.co.uk) CBT therapist and
BABCP member, on for further discussion if you are interested.

To learn more about Sumud Palestine visit: http://sumudpalestine.org.uk/

Fear of losing control of your bowels

The following was my reply to postings on the BABCP "CBT Cafe" discussing possible applications of a cognitive model for the treatment of the fear of losing control of bowels that seemed to be lacking in attention to the behavioural and physiological component of the disorder.

Re: Fear of losing control of bowels - Panic Disorder or Specific Phobiaa
« Reply #6 on: September 26, 2013, 10:35:58 pm »
Quote
Hi
Back in the old days (pre CBT) just about the only training in Behavioural Psychotherapy was for nurses, bowel and bladder habits were regarded as our bread and butter. So you could try an alternative to Clarkes formulation from 1986 with a greater emphasis on the A and B than the C and always informed by the ABC. Lots of conditioning stuff and negative reinforcement going on. Based on stuff,

 that Rob Newell and Pete Henderson taught me as a trainee.
Fear of soiling self – often following traumatic brown pants experience.
Aversive consequences, of shame and humiliation leading to avoidance behaviour.
Increased fear of soiling leads to increased self-focus on bowel or bladder fullness.
Increased awareness of bowel or bladder fullness follows and the client responds by urinating or defecating with the slightest stimuli.
In other words they stop holding and retaining and as a consequence of not squeezing and holding the muscles get weaker. Awareness of reduced capacity to hold and retain increases fear and acts as confirmatory evidence
Increased use of the toilet as a “precaution” and other safety behaviours (eg; dietary restraint, use of Imodium) maintain fear.
Treatment might include:-
Education on normal effects of anxiety on the G.I tract and impact on anticipatory anxiety leading to safety behaviours and or avoidance.
Baseline recording including bowel/ bladder movements, diet and medication use
Bowel/ bladder retraining exercises, monitoring and recording times from urge to voiding, holding both before going to toilet and after sitting on the seat, establishing regular bowel habit.
All this with exposure in imagination to feared consequence (soiling self).
By this time you have a real good idea of how long the person can retain on best and worst days.
Hopefully you have reduced anxiety response through exposure in imagination, stimulated awareness of ability to hold and retain, improved muscle tone.
Now push the exposure in real life, not just going out further from safety zones but including exposure in imagination to soiling yourself.
A good exposure exercise is to encourage the client to cack themselves in a controlled way. The idea is that they stand in the bath until they cack themselves. Many will find that the turds retreat and if not they can start to actually discriminate when the turtle is about to touch the cotton. Realising perhaps that they were not on the edge of soiling themselves they were several yards or maybe miles from the edge of brown pant gorge. Include imagining they are at a formal dinner party.
Some adaptations with IBS but too little time to go into this. But, similar principals apply with a greater focus on arousal reduction, mindfulness meditation exercises (also introduced to us at the Institute of Psychiatry by Padmal De Silva in 1986).
I am available for weddings and Bar Mitzvahs





Happy days Dave!!!!!!!!!!!!!!!!!!!!!!!!!!!!! It still works a charm.

Obviously 'it still works a charm' is less than empirical. That said I'd love to see a presentation on a BE involving testing a hypothesis regarding faecal incontinence being tested by cacking into a bath being presented by any profession other than nursing at BABCP conference. Obviously, that would have to get past the Scientific Committee and they are never going to let anything past that is anything less than 'compliant.

Mick

Great stuff! Brings me right back....Fionnula

Hi David,
Your behavioural programme brought back inspiring memories of work at the Psychological Unit at the Maudsley Hospital in 1990 when l did the Adult Behavioural Psychotherapy nursing course.
Our director was of course Professor Isaac Marks who would demand that the treatment of choice for this specific fear of incontinence would be the exposure programme you outlined and he would not have countenanced a cognitive approach.
Great days and times and l believe as do other therapists that the behavioural aspect of CBT has been superseded by the cognitive therapy acolytes.
Alan

God Got Bored On Sunday. A poem by David Raines

God Got Bored On Sunday

God got bored on Sunday and in a mischievous kind of way
said “I’m gonna make religious leaders start to justify their pay”.
Saying ‘Mary’s gone agnostic down in Accrington,
and ‘one of you has got to save her from hell’.
They were all put together in a call centre
and told “you’d better give the girl a bell”.

The pope called Mary on Monday
and said ‘I want to make a Catholic out of you.
I’ve got a papal dispensation here
I can forgive the things you do’.

She was phoned by Desmond Tutu on Tuesday
And in a cosy Christian kind of way
He tickled her with his laughter and
tempted her to pray.

Wednesday bought a call from a Witness
who said ‘judgement day is near’.
She guessed his tales of the ‘end time’
were supposed to fill her full of fear.

While talking to the Ayatollah on Thursday
she had to put the Dalai Lama on hold
she forgot for hours that he was waiting
but his patience was a wonder to behold.

By Friday Mary’s phone was humming
She had all the religions in a queue
Sikh’s and Muslims and Mormons
Taoists, Baptist’s and Jews

Her head was spinning when a Dervish called
late on Saturday night.
But, he couldn’t get her to turn with him
though he tried with all his might.

God called Mary on Sunday and said
“have you time to speak”.
Mary said it’s nice to hear you voice
you’re the first girl to call all week.

©David Raines 2011

Is IAPT dying?

IAPT Dying?

David Raines AKA Gabblewack.

Is IAPT dying? I’m minded to ask. It’s been eight years since Layard laid out the task With a unified vision, a national plan, And a big wad of dosh the endeavour began.

We seem to have increased access, as the initials purport; A million people treated, says the three-year report. Forty-five percent of those hit recovery rates, Though what constitutes “recovery” is up for debate.

Five percent “off benefits,” “economic gains.” So why is it this sense of unease remains? It isn’t that clear; it’s hard to decide: Did they return to work, or were benefits denied?

Layard’s calculations may have been sound But formed at a time when there were more jobs around. When they laid the pathway and put down the cash, They didn’t foresee the financial crash.

Higher unemployment, applicants abound; Now how does that history of mental health sound? They won’t ask about it at the ESA reviews; You’ll be found fit for work if you can bend and touch your shoes.

On a raft of new measures that come into play, We embark together on All Fools’ Day. Drifting off to sea with a forecast of storms, Loaded with a cargo of benefit reforms.

Legal aid cuts, changes in employment law, Will make it easier for employers to show you the door. Benefits capped and bedrooms taxed, The belt has been tightening—it won’t be relaxed.

Maybe ‘Work Capability Neurosis’ is the diagnosis to be used, Describing pathological fears of having benefits refused. Or ‘Post-Work Capability Assessment Disorder’ is better, Describing the impact of the judgement letter.

Care Commissioning Groups are here, the new season’s fashion, Giving GPs the right to share out the rations. When it comes to decisions about what is to be bought, Will it be evidence-based practice or ongoing support?

So will IAPT fit in with the CCGs’ plans? Will it flourish and grow in the GPs’ hands? They seem at ease with disease, with infection and plague, But when it comes to mental health, they’re disturbingly vague.

As the huddled masses start knocking at the doctor’s door For their prescriptions to relieve the effects of being poor, Will they be poring over NICE guidelines, or referring everything To the nice lass down the corridor who does some counselling?

Black Dog

BLACK DOG

David Raines  AKA  Gabblewack

As you lie in bed and the whole world’s sleeping
then the thoughts rattle round in your head.
When the only sound is your own heart beating
and the black dogs breathe on your neck

Certain of your self conviction.
Fooled the others, can’t fool yourself
Black Dog heard your first tear falling
Black Dog feeds on your fear

Amplify, exaggerate,
distort and then condemn
Make yourself your judge and jury
then let the sentence begin.

Choked by the fear of your future failures
Paralysed by past mistakes
Then desperate for sleep with dawns light rising
as the rest of the world awakes

Alone in the gleam of the harshest spotlight
revealed your shame is clear.
Black Dog heard your first tear falling
Black Dog feeds on your fear.

When you look in the eye of the storm that’s raging
Who do you see looking back?
Can you see through the smile to the shadows behind me
where there’s a dog crouched low to attack?

Druids and Welshmen

This poem draws its inspiration from a news report highlighting a striking geographical symmetry: the landmass of Wales is essentially equivalent to that of Israel, while the area occupied by the Snowdonia massif mirrors that of the Palestinian territories. By mapping these familiar landscapes onto the geography of a distant and complex conflict, the poem explores the human experience of these lands, grounding universal themes of displacement, belonging, and memory within the terrain we know best.

A Promised Land

David Raines AKA Gabblewack

Imagine the Druid’s claimed Wales as their own
and from four corners return to their ancestors home.
For centuries their forebears the “Silures” lived there,
before exiled by Romans they roamed in despair.

History records over centuries to come
slaughter, injustice and dark deeds done
The Druids were desperate, convictions ran high
the time of return to ‘Siluria’ was nigh.

After centuries of oppression, exile and pain
they returned to their homeland to settle again.
Slowly at first so it didn’t look planned
the Druids bought whatever they could of the land.

The Welsh weren’t too happy as more Druids arrived
fearing dreams of their own nation would soon be denied
Most Welshmen weren’t Druids but sons of Cymre
with no less desire for their own liberty.

But hot headed radicals soon had their say
shouting “throw all the Druids in Cardigan Bay”,
“druids eat babies”, “they’ll kill you at home”
as the seeds of the conflict were liberally sown.

Peace slipped out slowly and I’m sorry to say
Politics and religion just got in the way
Looking for friends each side cast around
as support was enlisted and allies were found.

The Druids had close links with Gaul (now France)
and the French were determined to give Siluria a chance.
From Swansea to Bangor, from Caerphilly to Neath
The Druids were now all armed to the teeth

Scotland and Ireland answer their Welsh cousins call
pledging aid and predicting the Druids will fall.
The Welsh were armed with promises made
that their cousins the Celts will come to their aid.

Anger bred anger and gave birth to strife
as an eye for an eye moved to life for a life.
After years of keeping the two sides apart
the English, as usual decide to depart

The UN debate and decide to divide
splitting the country with half to each side.
The Druids rejoice as Siluria is born
and the Welsh awake to a tenuous dawn.

The Celt alliance with it’s arsenal full
couldn’t decide which direction to pull.
The Druids were united, well armed and supplied
winning most of the battles they advanced on all sides.

When the dust settled and the ceasefire was signed
from Monmouth to Fishguard they’d drawn a green line.
Displaced and dispersed floods of Welsh refugees
left homes and crossed borders by land and by sea .

Fifty years later after numerous wars
Wales is confined to Snowdonia and Anglesey’s shores.
Some Druids emboldened now strengthen their claims
saying Wales never existed it was only a name.

The Welsh it turns out are a troublesome lot
they revolted and rioted from Maesteg to Splott.
They stubbornly resist signing any Druid plans
that don’t involve the return of their lands.

Some people argue that the French are to blame
their military assistance tipped the balance of the game.
Four point 9 million dollars is the figure they say
That the French give the druids, every single day

The Druids removed churches built on  ancient sacred sites
and settlers in Snowdonia now control the strategic heights.
They are confident in their security as the darkness falls.
Now the government has built them an exclusion wall.

I supported the Druids after all they’d been through
but I’m struggling to justify the things that they  do.
Critical comments  raise the finger of blame
“ anti-druid” they say and then

mark you with shame.


Now I ponder and wonder , how is it justified
to excuse your injustices, because you ancestors died?
How many druids deaths did it take, over countless tragic nights
To legitimise the denial of the Welshmen’s rights.

Gabblewack