Try this, come back, and we’ll see

Creating great treatment plans

Anew patient – let’s call her Joanna – recently mentioned that she’d been to another practitioner, but had decided to try her luck elsewhere. Her reason?

“She told me to ‘Try this, come back, and we’ll see.’”

At fi rst glance, this might not seem like much of a reason to abandon a doctor. After all, much of what is done in practice is… well, practice. Being 100% confi dent is a luxury we rarely have. “Try this and we’ll see,” simply isn’t that uncommon.

But what Joanna was upset about was not the lack of surety, or the possibility that her care was a bit of an experiment. She simply felt that there was no plan.

And she was right. Try this and we’ll see isn’t a treatment plan any more than one line on a page is a novel. Yet it’s surprisingly common.

Much of the reason stems from putting too much emphasis on treatments. e tools of our trades are deceptive – it’s easy to believe that what you do as a practitioner is about the needles or the herbs or the supplements. But an acupuncture treatment isn’t a plan. Nor is a homeopathic remedy or a supplement. ey’re treatments, not plans. And how they’re used is a prescription, not a plan.

Joanna had a prescription and it wasn’t enough. So what was she missing?

Why Plans Are Important Joanna was craving a plan. A way to understand her treatment in a larger time frame, and how it fi ts in with her symptoms and overall health. And she’s not alone. Patients love plans. Here’s why:

Plans Create Context

Joanna’s not an outlier. She might have been better at articulating her desire for a treatment plan, but she’s not alone in her desire to have one. Patients crave context for their treatment. It’s how they understand that they’re on a path from A to B, and how they manage the anxiety around their health and care.

Even if they’re terrible at making a plan for themselves, patients love when you make one.

They Help Results

The simple act of mapping out treatment seems to have a placebo eff ect of its own. It gives patients a sense that they’re in capable hands, on a journey with a clear route and destination.

Plans Demonstrate Progress

Care takes time. Not everything resolves overnight, particularly chronic complaints that are built over years. A plan provides the context for seeing the slow, steady progress that can be invisible at times.

They Help Create Successful Outcomes

Plans make for commitment, commitment helps compliance, compliance creates success, and success makes more of itself. Want better results? Make a better plan.

What a Good Plan Looks Like

From the patient perspective, a good plan is a clear map from where the patient is to where she wants to be. It’s a health care road trip, with a clear destination, a route and waypoints along the way.

Here are the key high points your plan should hit:

Goals

What are you trying to accomplish? Are you sure you know what success looks like? Better still: does your patient know? Ask them what success looks like for them and make sure you’re on the same page.

Measurement

How will you know when you get to success? What can you measure that will let you know when you’ve arrived, and whether or not you’re headed in the right direction? Objective testing isn’t just a diagnostic tool for doctors – it’s a marker for progress that is hugely benefi cial for patients.

Visit Frequency

Return visits matter, and for more than just treatment – they’re how you track the progress of the plan. But visit structure and rationale are particularly important to clarify for consult-based care.

It’s easy for patients to know why they should come back for their next acupuncture treatment: to get the treatment. But the importance of a follow-up consult may need more clarity. Clearly state the visit structure, and the why behind it.

Tools and Techniques

What are you using to get from where you are now, to where you want to be? is is the area we tend to be best at, but have you explained to your patient why you’re using the modalities you are?

Timelines

What are the timelines? How long until your patient will see results? How long until she reaches success?

Alternatives

What are the options if the proposed plan doesn’t seem to be working? At what point do you consider them? Why are they alternatives, and not part of the active plan?

Even the Best-Laid Plans

Planning is surprisingly easy, but also surprisingly prone to three key pitfalls.

1. Believing ere’s not Enough Time to Plan

It’s easy to think that describing a treatment plan this way is too complicated to work through in an already-crowded visit.

But don’t be fooled. Joanna’s plan, properly laid out, takes just a few moments to communicate. Not a huge investment given the potential return.

The following example might take two, perhaps three, minutes to clearly explain to a patient:

I suspect the root of your problem is a food intolerance. It’s creating a chronic infl ammatory response in your body and your digestive track. at result is a magnesium defi ciency, and that’s what’s causing your migraines.

We’re going to remove your reactive foods from your diet, and see you once a we ek for the next 4-8 weeks for IV magnesium to treat the headaches. If the treatment works, we’ll decrease to once a month treatments after that for a year.

If we’re on the right track, you’ll notice a diff erence within the next 4 weeks, but it’s likely going to take 10-12 months for you to fully recover.

CRP, which is a measure of infl ammation, is elevated in your blood. We’ll measure this every 3 months to make sure it’s decreasing. We’ll follow up every 3 months to discuss the lab result, monitor your symptoms and tweak your treatment plan as needed.

2. Not Sharing the Plan e most common planning pitfall among doctors is that they already think they have a plan. And to be fair, you probably do.

You just might have neglected to tell your patient.

It’s easy to forget that your knowledge and experience make most aspects of the treatment plan seem obvious. So obvious that you don’t need to mention them. Remember, though, that your patient is a) not an expert and b) possibly overwhelmed with everything else you’ve told them during their visit. ey likely can’t create the plan themselves. at’s why they’ve come to you.

3. Too Much Information

Don’t confuse plans with information. A binder full of recipes, handouts and information sheets isn’t a plan – it’s just more information, and if anything it makes it harder for patients to understand and embrace the larger context of their care.

Plans are about broad strokes. ey’re about how to get from Toronto to Vancouver, not about tire pressure or the price of gas. Err on the side of over-simplifi cation. State the obvious, briefl y and clearly. en state it again if you need to.

Plans Help Everyone

A great plan is good for you and your patients. It leads to higher success rates, greater patient satisfaction, and as a result, more referrals.

Used properly, great treatment plans can help you fi nd that unique junction where benefi ts to patient, practitioner and practice overlap – the sweet spot of professional success.

Losing patients? Try better planning. Need more referrals? Try better planning. Want to feel more confi dent about your professional skills? You guessed it…better planning.

Cognitive Behavioural Therapy

Application in clinical practice

Most health practitioners are aware of cognitivebehavioural therapy (CBT). CBT is one of the most studied and most relevant treatments in psychotherapy, with very positive research outcomes. It is short term, focused in the present, and evidence based. Cognitive-behavioural techniques can be quite specifi c but they are also highly adaptable, making them an important component of many diff erent treatment approaches and applicable in a variety of conditions. CBT is well established as a core treatment for many psychiatric disorders (Butler 2006); however, the usefulness of CBT is not limited to mental health concerns. CBT has been shown to reduce distress and improve outcomes related to a number of medical conditions, including chronic fatigue (Malouff 2007), type 2 diabetes (Gonzalez 2009), HIV (Safren 2009), and cancer (Osborn 2006). Cognitivebehavioural therapies can also be applied to help a healthy person optimize their wellbeing. Using CBT to identify and challenge the specifi c belief systems that perpetuate disturbance can help to both shift physiologic experience and promote self-empowerment. ese goals are inherently a part of our naturopathic philosophy and an expression of the mind-body connection.

The CBT Story:

A psychiatrist named Aaron Beck, MD first presented CBT as a specific treatment for depression in the early 1960s. Trained as a psychoanalyst, Dr. Beck began noticing how particular streams of negative thought became active during therapy with depressed patients. Recognizing that these thoughts were not consciously derived or acknowledged, Dr. Beck termed them “automatic negative thoughts.” Dr. Beck also noticed that automatic negative thoughts tended to relate to unconscious beliefs in one of three areas: negative beliefs about oneself, negative beliefs about the future, and negative beliefs about the world. Rather than working through these streams from a strictly psychoanalytic perspective, Dr. Beck began developing tools to help patients directly identify and evaluate the content of their thoughts. By bringing conscious awareness to these automatic and unconscious beliefs, Dr. Beck was able to help his patients begin to think more realistically. As patients began to consciously shift their thinking patterns, they began to feel better emotionally and were able to behave in more effective ways.

From these beginnings, an evidence base spanning 50 years of research has challenged CBT to grow as a treatment modality. CBT has been specifically studied as a treatment for depression and other mood disorders, anxiety disorders, eating disorders, addictions, recovery from trauma, and in the treatment of many medical conditions (for detailed list see Beck Institute 2011). Current research continues to examine the efficacy of CBT in a variety of mental health conditions (Hofmann 2008, McCarthy 2007, Roberts 2009) as well as its role in mindfulness-based therapy (Hofmann 2010) and healthy psychological adjustment in non-clinical populations. With such a rich research history behind it, contemporary data on CBT has become increasingly refined. For example, Cape and colleagues (2010) evaluate the use of a brief-form CBT in primary care as a treatment for anxiety, depression, and mixed mood disorders. Hart and Hart (2010) consider the values and limitations of CBT in a behavioural medicine context. Another interesting perspective (Spek 2007) explores the use of internetbased CBT and alternate delivery forms that make CBT tools much more widely accessible. Although the literature will continue to evaluate and critique the clinical parameters of CBT, its value as a psychotherapeutic tool is evident.

Next Steps: With an abundance of data to draw from and clear indications for the use of cognitive-behavioural therapies, the next question is how a naturopathic doctor can utilize the resources provided by a CBT model. Even without specific training in CBT, there are practical ways that an ND can apply cognitive-behavioural principles within a naturopathic context. While cognitivebehavioural methods may be of particular interest to those who treat patients with anxiety and depression, it is important to remember that these tools are much more broadly applicable. If we consider maladaptive belief systems as an obstruction to Vis, then we can begin to understand how beneficial cognitivebehavioural restructuring can be with regards to overall health. Recent advances in the science of epigenetics demonstrate how deeply organizing our perceptual systems are with regards to our physiology. In his work on the biology of belief (Lipton 2005), Dr. Bruce Lipton, PhD, explains how perception mediates cellular behaviour and biological expression. Our core beliefs and perceptual habits exert a significant influence on cellular behaviour and are strong epigenetic regulators. Informed by this perspective, we can begin to harness the restorative biological power that comes with increased freedom from cognitive distortions and limiting beliefs.

There is not just one way to use CBT in a naturopathic practice. For people who prefer a more structured and linear approach, there are some great resources on the market that will take you through the process step by step. For practitioners who would like to integrate a more general use of cognitive-behavioural therapy within a naturopathic framework, I will offer some suggestions as to what this might look like. The most important components of any cognitive-behavioural therapy include the capacity for self-reflective awareness, learning to identify specific thought patterns, and restructuring maladaptive belief systems. NDs can implement a cognitive-behavioural approach to health by helping patients to first become more aware of their thoughts and then learn to observe them without reacting to them. The goal here is to identify specific words, expectations, and assumptions that have a negative influence on a person’s wellbeing and to understand the context in which those thoughts become active.

Begin by noticing if there are certain words that a patient frequently uses to describe themselves, their life situation, or their relationships. What words have adverse energy for that person and in what context? Do the automatic negative thoughts tend to be active in all domains of life or are they more prevalent with regards to the way a person views a specific aspect of their life? (eg: self-image, home, work, relationships, family, health, finances, etc). What automatic assumptions are attached to those thoughts? How do those thoughts impact the person’s emotional state? Their body sensations? Their relationships? Their behaviours? By consciously identifying automatic negative thoughts and describing their impact on other aspects of experience, patients are able to begin separating themselves from their thinking and can better see the connections between thoughts, feelings, and behaviours.

As you teach patients to become more aware of their own thought patterns, you can actively challenge negative self-talk within an appointment by reflecting negative thought streams back to patients and asking them to consider the validity of that thought (“I hear you say quite often that you’ll never be healthy; do you believe that is true?” or “I’ve noticed that you tend to put yourself down when you are talking about your family; do you believe that you are less worthy of love than your siblings?”). Once you have identified a problematic thought, you can challenge the patient to discover whether or not that thought is true. Although it may feel 100% true, it often is not. Engage the patient by asking them to give evidence for the truth of a particular thought. Then ask them if there is any evidence that the thought is not completely true. You can expand on this by asking them to consider at least one alternate perspective (“How else might you explain this? What else could it mean?”). This kind of therapeutic conversation challenges patients to begin questioning and changing their cognitive habits.

Thought records are another way to help patients develop self-reflective awareness and learn to identify cognitive patterns. Patients are asked to track their thoughts, writing them down each time they become aware of them throughout the day. There are many resources available for learning to keep thought records, and essentially they all teach people to notice and evaluate their self-talk. Many thought records also include instructions on how to identify and label automatic negative thoughts (for example, is this thought a catastrophizing thought? A “should” thought? An all-or-nothing thought?), as well as how to create a habit of thinking more realistically (eg: changing “I’m never good at anything” to “even though I didn’t do as well as I would have liked, I still passed the exam”). Teaching people to become aware of and challenge their thinking can be an empowering step towards change.

Once a person has become more conscious of their self-talk, it is usually fairly simple to see that these automatic negative thoughts cluster around certain themes. As themes begin to appear within the automatic thought patterns, you can track them to underlying core beliefs. For example, automatic negative thoughts could cluster around themes of mistrust, autonomy, shame and guilt, competence, inferiority, perfection, intimacy, protection, or meaning. While there are limitless possibilities as to how these themes express themselves, they typically relate to the ways we view ourselves, the world around us, and our future potentials. Often they have to do with perceptions related to one’s worth as a person, the ability to give/receive love, the expression of power/control, and the desire for acceptance. As we explore the belief systems that motivate our feelings and behaviours, we start to identify perceptual distortions that limit our experience of the world. In homeopathic terms, these can be considered “delusions” and those with a homeopathic mindset will find that they can prescribe on the experience of these themes. The same idea applies to TCM: as you clarify the energy of the belief system you can correlate it with the five elements or mental-emotional patterns of specific organ imbalances and treat accordingly. From this perspective, cognitivebehavioural approaches are not only independent therapeutic tools but also provide a level of understanding that is helpful when applying other treatment modalities. Prescribing from this level allows for an expression of “treat root cause.” What we are trying to do is isolate belief systems that perpetuate disturbance in physiology, psychology, and behaviour. In other words, the belief system itself is pathogenic and once we understand its role, we can apply any of our naturopathic modalities to help correct it.

Belief systems create the perceptual configurations for the experience of life. As these belief systems become more visible, a range of options opens up to you and you can actively engage in a restructuring process. You can recognize the origins of some beliefs (“my father told me that winning is the only thing that matters”) and with compassion begin to let them go. You will find that some beliefs shift easily and others are much more entrenched. Sometimes it helps to directly challenge the truth of these belief systems and evaluate the data that supports/refutes them, and at other times it is better to just question whether or not the belief is helpful in the present. A good question to ask is, “how does this belief contribute to my health, happiness, and wellbeing?” If the answer is, “it doesn’t” then ask the patient what holds the belief in place, what sustains its presence in their psyche. Evaluate the justifications for keeping the belief and consider the possibilities for releasing it. “Who would I be without this belief” is another good question for discussion.

It is important to remember that cognitive-behavioural tools are most efficacious within a comprehensive and individualized approach to treatment. Some patients may just need direction to available resources and encouragement towards self-study; others may appreciate a workbook-style approach where you work as a team. Some patients may respond well when you engage in therapeutic conversation around a belief, allowing them to recognize it for themselves and encouraging them to examine the patterns in place around that belief in their lives. Some patients will enjoy a cognitively-oriented approach to working with belief systems but others may benefit from focusing more on the emotions, images, or sensations associated with the belief. Other people will do best when they are behaviourally-oriented. Understanding your patient as an individual keeps you true to the philosophy of naturopathic medicine and it also allows you to customize treatment so that it is as effective as possible. Whether you are drawn to a more cognitive approach to CBT or if you can better relate to cognitive work through another form like homeopathy, guided imagery, TCM, or body-based therapies, there are many ways that our profession can serve others through responsible use of functional psychotherapy.

References:

Beck Institute. www.beckinstitute.org Accessed January 2011.

Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev. 2006 Jan;26(1):17-31.

Cape J, Whittington C, Buszewicz M, Wallace P, Underwood L. Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression. BMC Med. 2010 Jun 25;8:38.

Gonzalez JS, McCarl LA, Wexler DJ, Cagliero E, Delahanty L, Soper TD, Goldman V, Knauz R, Safren SA. Cognitive behavioral therapy for adherence and depression (CBT-AD) in type 2 diabetes. Journal of Cognitive Psychotherapy. 2010;24(4):329-343.

Hart SL, Hart TA. The future of cognitive behavioral interventions within behavioral medicine. Journal of Cognitive Psychotherapy. 2010;24(4):344-353.

Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. J Consult Clin Psychol. 2010 Apr;78(2):169-83.

Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008 Apr;69(4):621-32.

Lipton, Bruce. The Biology of Belief. 2005. Malouff JM, Thorsteinsson EB, Rooke SE, Bhullar N, Schutte NS. Efficacy of cognitive behavioral therapy for chronic fatigue syndrome: a meta-analysis. Clin Psychol Rev. 2008 Jun;28(5):736-45.

McCarty CA, Weisz JR. Effects of psychotherapy for depression in children and adolescents: what we can (and can’t) learn from meta-analysis and component profiling. J Am Acad Child Adolesc Psychiatry. 2007 Jul;46(7):879-86.

Osborn RL, Demoncada AC, Feuerstein M. Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: meta-analyses. Int J Psychiatry Med. 2006;36(1):13-34.

Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI. Systematic review and meta-analysis of multiplesession early interventions following traumatic events. Am J Psychiatry. 2009 Mar;166(3):293- 301.

Safren SA, O’Cleirigh C, Tan JY, Raminani SR, Reilly LC, Otto MW, Mayer KH. A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals. Health Psychol. 2009 Jan;28(1):1-10.

Spek V, Cuijpers P, Nyklicek I, Riper H, Keyzer J, Pop V. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychol Med. 2007 Mar;37(3):319-28.