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Part 4: Guides to Therapy & Treatments

Interview w/ Chris Edwards, Clinical Pysch.

Jasmine: As far as the client is concerned, after say 4 or 5 sessions and they feel they are not getting anywhere, what should they do?

Chris: I think, at the minimum, they should talk to their therapists and try to establish why this is the case. It could well be that there is very good reason for it. What I haven't covered is that sometimes people feel that they need not only be comfortable with the therapist, but they also feel that they need to be comfortable with the therapy. They should take comfort in an understanding of the therapy. However, quite often good CBT is pretty boring therapy. And it is often not all that pleasant.

In some recent research, people described CBT as "bitter medicine" and I think that is a very apt description of it. Most people at the other end of therapy describe it as "bitter but useful". Other people take to it with relative comfort. If you are a person with very high anxiety sensitivity, then you are going to be very suspicious of anything which causes any change or any increase in your level of physiological arousal. Even working on your problem at a thinking level can cause some distress. So, it is sometimes unpleasant but if you understand it, it is usually tolerable.

Jasmine: What about the clients that are trying to "please" the therapist? The story about the guy that kept going back to the therapist saying "I'm getting better, I'm getting better" but he was actually getting worse and he didn't want to let the therapist down.

Chris: This happens all too frequently. I think the important thing is for clients to work collaboratively with their therapist. If they are saying they are getting better when they are not, there is only going to be one loser and that is the client because it means they are not going to get their needs met. Of course, the therapist might feel bad as a result of not been able to help their client, but that's our problem. It's a worse thing for the therapist, if the client keeps it a secret. The therapist will never understand why they are not helping the client. Therefore, the therapist fails to learn from this kind of therapeutic experience.

Jasmine: Some people feel guilty if they make the therapist feel bad. It's a whole cycle .. being a nice person ...

Chris: It's an interesting dilemma. Trying to not make the therapist feel bad. If it's a good therapist who cares about their work, they will be more interested in the client who shares their problems.

Jasmine: Many people complain that all the good therapists are psychologists, but they can't afford to see them. Where do you stand on the issue of Psychologist treatment being paid in part by Medicare?

Chris: I think it is an excellent idea. I don't think there are any moves afoot for that to occur, but it would certainly help. Psychologists are fairly expensive. However, if the psychologist has the skills they need, it may not be expensive in the long run. If a person goes and sees a person who isn't helpful, then they will find themselves paying for bad therapy for a long period of time. The individual needs to consider both the economic and social cost of delaying their treatment.

A Senate Committee report released last year recognized that Psychologists were being under-utilized in the care of patient's emotional disorders. In reference to Anxiety Disorders, much of the evidence came from psychiatrists, support groups, and psychologists who worked in those areas. The federal government did recognize that this was a problem but handed responsibility back to the States by suggesting that they should work out ways in which they could employ more Psychologists. This looked like an attempt to avoid the issue of losing control of costs by extending Medicare to another group of people. In some ways, their concerns are justified in that psychologists have such a broad range of differing qualifications, it would be quite hard for them to work out who they should pay and who they shouldn't. It is a difficult issue and I don't think we are any closer to resolving it at this present time. It's something that I would like to see resolved.

Part 5: What is available for people in rural areas, GP training for Anxiety Disorders & CBT

Jasmine: Many people live in rural areas of Australia where the support for Anxiety Disorders is at best minimal. What suggestions do you have for them as far as getting help?

Chris: There are some really interesting things beginning to happen in that many of these people in the future will be able to receive some assistance through the Telemedicine program which is being run by the State Mental Health service. In particular, one of the psychiatrists that works in that program is Fiona Hawker. She is a very experienced therapist with people who have Anxiety Disorders. Secondly, another very experienced psychologist in the area of Anxiety Disorders, Andrew Livingstone, has taken up a position with that service. So the rural and remote services are likely to be very well served with people experienced in Anxiety Disorders. That, of course, doesn't solve the whole problem. Now, another large chunk of the problem is currently being taken care of by the Panic Anxiety Disorder Association, which visits the country quite regularly and perhaps are providing the biggest service to people with Anxiety Disorders in the country at present.

Even with those things working in the favor of country people, there is still the tyranny of distance, where people may be housebound, they may not even be having contact with people who recognize and understand that they have disorders. For those people, I think organizations like PADA and the Anxiety Disorder Foundation need to be taking a health promotion view of things, where they can continue to increase community awareness about the incidence and possibility that help is available. Another thing which might help people in the future is manualized treatment programs. That is, workbook type programs which are specifically designed for people with Anxiety Disorders. However, having said this, my own experience has been that these only work well when they are combined with the assistance of a therapist.

Jasmine: Even so, this is better than nothing.

Chris: It is better than nothing. And if the motivation is there, and it is a good workbook which they understand, then they can go a long way. The important thing when using a workbook is to complete all suggested exercises rather than just reading the book.

Jasmine: What about a National Telephone Support Line for people in the rural areas?

Chris: In order for support to be useful, it has to have some very specific objectives. Now, if support means that a person is supported by the "Now, now you will be alright .." type support, that wouldn't be useful at all. If just listening to a person's problem is all that is going to occur, it may, in fact, be detrimental.

There was once a psychologist that said that a person knows what they think when they hear themselves say it. So they not only need to be able to share their problems, but they need to be able to have a method of constructively looking at the issues involved in the problem. They need to be able to have some understanding of how the problem operates. Now that could be disseminated through written information. For example, Bronwyn's book is one way that people have gained very good understanding about the nature of their problems and more importantly some solutions. Consequently, a good telephone support service will usually make use of other resources like books, allow people to share problems, and prompt them to find solutions.

Jasmine: Another issue for clients of Anxiety Disorders is the lack of training/ understanding of Anxiety Disorders by General Practitioner's. Can you tell us about the General Practitioner training you are currently supervising?

Chris: Let me start off with a more positive note. There is a growing awareness amongst General Practitioners of Anxiety Disorders and I am aware of 3 or 4 projects which have been set up at present to actually assist General Practitioners to

• understand the nature of anxiety disorders to help to them diagnose them; and
• to provide some level of intervention.

In respect to our program, it was intended to teach general practitioners about cognitive behavioral strategies that they might use to assist their clients to manage their Anxiety Disorders in a better way. One thing that consumers have complained about is a lack of diagnoses. So the first thing that general practitioners were taught in my project was how to diagnose Anxiety Disorders.

General Practitioners, overall, treat a large number of medical conditions. So it is perhaps unfair to expect that every General Practitioner should be able to diagnose and treat Anxiety Disorders. So, there will be some General Practitioners who develop a very clear focus and wish to treat the person's Anxiety Disorder wholly.

General Practitioners are usually the first person to see people who develop Anxiety Disorders. By teaching them not only to diagnose but to provide an immediate cognitive behavioral approach they will have an important role in preventing more serious Anxiety Disorders from developing. I think their most powerful role is in the prevention of more serious Anxiety Disorders. If a project achieves nothing else but to be able to help General Practitioners communicate and prevent the deterioration of Anxiety states, then I think it will have been very successful.

Jasmine: I agree. Many clients say "If only I had been told earlier." Even the span of a couple of months makes all the difference.

Chris: Oh yes. It makes a huge difference. Some people almost seem chronic in a week. One of the things the General Practitioners have told me is that they want to be able to offer an immediate intervention for their clients. Almost without exception, General Practitioners have said, by learning Cognitive Behavioral skills, it has given them a another way of communicating with their patients.

Jasmine: CBT revisited ...

Chris: Let's just say a few more things ... let me give you a summary. Cognitive therapy packages use a fairly wide range of cognitive and Behavioral procedures to help their clients change. The first set of treatment strategies help their client to change misinterpretations of bodily sensations. The second lot of Cognitive treatment strategies are aimed at modifying processes that tend to maintain the misinterpretations. Now, a third sort of cognitive intervention is a review of a recent attack. We are not so much interested in the history, but in actually reviewing a person's understanding of an attack. Helping a person to look for explanations which might be involved in the misinterpretation and then helping them to consider a number of alternative explanations. Additionally, techniques are also used to help people to consider explanations for images. These were previously considered not to be all that important; but now we know that many of our people have very vivid images and if we only treat the sensations, and not the images, then they are likely to remain symptomatic.

A behavioral strategy might be to induce a fear sensation and that's called an interceptive technique. You might have a person focus their attention on their heart rate and see if they can discover the reasons why their heart rate might increase as they focus their attention on it. So that is a summary of Cognitive Behavior Therapy.

Jasmine: Thank you very much Chris for your time.

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