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