Working with people who are anxious or low in mood

11 Working with people who are anxious or low in mood



Chapter aims




• To describe the Five Areas model of assessment and formulation


• To describe a series of psychological interventions, underpinned by a cognitive behavioural therapy approach, which aim to:


– challenge unhelpful thinking styles

– overcome reduced activity

– overcome increased anxiety

• To identify how these interventions might be applied to your mental health nursing practice



Introduction


The interventions and clinical skills described in this chapter are informed by a cognitive behavioural therapy (CBT) approach (see Ch. 3). There is a growing evidence base for the effectiveness of these interventions when working with people who are anxious or low in mood. Additionally there has been strong political support to increase access to psychological interventions in the UK which has led to investment in specific training and service programmes (Department of Health 2008). Efforts have been made to identify the positive elements of a CBT approach and adapt them so that a greater number of practitioners can feel confident using them in mainstream mental health practice. The interventions described here utilise these adaptations and are reflective of the contemporary ways in which CBT is delivered in mainstream services. More information and resources on this approach can be found at http://www.fiveareas.com/resourcearea/ (accessed June 2011). Specialist services do still exist where experienced CBT therapists adopt more traditional approaches and work with people with complex problems.


The interventions described here attempt to improve anxiety and low mood by influencing the way a person perceives and responds to specific situations. This involves conducting a thorough assessment which identifies how a recent life situation alters thinking, behaviour, emotional and physical feelings and how these areas impact on each other to lead to a problematic response. Interventions will commonly focus on changing one of these areas as a way of breaking unhelpful cycles of thoughts, feelings and behaviours. This is based on the fundamental principle of CBT which maintains that what people think affects how they feel emotionally and physically and consequently what they do. Interventions are often short term and tend to focus on a specific problem in the here and now as opposed to past life events which have contributed to the person’s current issues. As a student on a mental health placement, you could be involved in delivering an intervention underpinned by this approach.



The Five Areas assessment model


The Five Areas assessment model recognises that when people are feeling anxious or low in mood their thinking can become extreme and unhelpful. For example, people may see themselves as worthless or incompetent which then leads to reduced or avoidant behaviours. The model identifies five domains within which a person’s problematic thinking and behaviour can be examined, and the links between each area can be established (Williams & Garland 2002a):



1. Life situation, relationships and practical problems.


2. Altered thinking.


3. Altered emotions (mood or feelings).


4. Altered physical feelings.


5. Altered behaviour or activity levels.


Focused and specific questions are asked to explore the problematic life situation and ascertain how it is impacting on or being maintained by the remaining four areas. For example:





Area 2: altered thinking




• How do you see yourself?


• How do others see you?



Area 3: altered emotions




• How would you describe your mood?


• How has this changed?


• How would you feel about …? (Describe specific scenarios to ascertain the emotional response, e.g. fearful, angry, guilty or embarrassed.)



Area 4: altered physical symptoms




• How would you describe your sleep, appetite, concentration, energy levels, etc.?


• How easy do you find it to relax?


• How would you describe the feelings in your muscles?



Area 5: altered behaviour




• What things have you stopped doing since you have been feeling this way?


• What things have you started doing to help you cope with the way you have been feeling?


(For a more extensive list of example questions, see Williams & Garland 2002a.)


This approach to assessment aims to inform interventions by identifying clear target areas for change, as making alterations in any one of the domains of the Five Areas model is assumed to lead to improvements in other areas. The model can easily be understood by service users and enables them to recognise their own patterns of thoughts and behaviours from a more objective position. Together the mental health practitioner and the service user can identify how the problem is maintained by specific thoughts, feelings and behaviours which allows them to see the potential for improvement.


The information gathered from the assessment process is summarised under the five domains in a diagram which identifies the relationship between the areas. This can be used to feed back to the multidisciplinary team so that the whole team can gain an understanding of the person’s problems and adopt a consistent approach to interventions. An example of when this could be particularly helpful would be if a service user is coping with anxiety through seeking constant reassurance. You may be working with them to change this behaviour and will require other members of the team to support this intervention by not giving reassurance when the service user requests it.


Once the assessment is complete, a plan for intervention is agreed by identifying the area which is likely to have the most significant impact on the defined problem. The following interventions are examples of approaches which are commonly adopted in mental health practice.



Challenging unhelpful thinking styles


The thinking style associated with a problem or behaviour will often become extreme or unhelpful if a person is experiencing anxiety or low mood. You may hear this referred to as negative automatic thoughts, thinking errors or cognitive distortions. They tend to be consistent and lead to misinterpretation of everyday situations. There are common unhelpful thinking styles which lead people to blow issues out of proportion or downplay their ability to cope with a problem. These could include the following:



• A high level of self-criticism.


• A negative attitude towards past and current events.


• Negative predictions about the future.


• Presuming others think badly of them without evidence to suggest that this is the case.


• Feeling responsible for poor outcomes.


• Taking feedback as criticism and personalising criticism which is not directly related to them.


• Holding high standards for self which are likely to be impossible to meet.


It is important to recognise that we all hold some unhelpful thinking styles and you may be able to apply some of the examples given above to yourself at times. These tend to become problematic when these thoughts become frequent and hard to dismiss which then leads to significant levels of distress.


In the following scenario, try to identify the unhelpful thinking styles which are present.



image Case history


Jane is a 38-year-old single woman who lives alone in a small flat and works as a legal secretary. She has been seeing her doctor for several months complaining of lack of appetite, feeling listless and no longer enjoying her work. After extensive tests revealed no physical health problems, her GP referred her to a psychiatrist for assessment. Although initially reluctant, Jane eventually agreed. The psychiatrist diagnosed Jane with mild depression and prescribed a course of antidepressant medication. Jane was reluctant to take the tablets and enquired whether there was any alternative. She was told about cognitive behavioural therapy which she chose to take up.


During the first meetings, Jane spoke about always feeling different and isolated from other people but things had become worse over the past few months following a date with a work colleague. Jane had never got on well with men and could see nothing in herself that men would find attractive. She had therefore resigned herself to remaining single and had arranged her life accordingly. When a colleague asked her out for a meal, she was flattered and immediately agreed. However, on reflection, she felt her decision had been hasty and was convinced he had only asked her out of pity. Her doubts were confirmed on the date when she acted clumsily and could think of nothing interesting to say. The next day at work her colleague made no attempt to ask her out again. Since that time Jane had found it difficult to talk to men and women. She felt her work colleagues were talking about her behind her back and that she was completely unlikable. She had also lost her desire to play her piano in the local church which was her main hobby.



image Activity


While on placement you should try to identify these thinking styles among the service users you are working with. You may also be able to recognise them within yourself and friends and family.




Stage 1: recognising unhelpful thinking styles


Interventions which aim to challenge unhelpful thinking styles start with helping the service user to recognise them, identify the impact they have on how they feel and what they do as a response. The follow steps will guide you through this process:



1. Use the list above (p. 165) to talk about if and when the service user has noticed adopting any of these thinking styles.


2. Ask the person to describe the general situations or events when they noticed the thinking style was present. Examples might include:


a. a job interview

Related posts:

  1. The practicalities of mental health placements
  2. Working with people to make choices about their treatment
  3. Working with people who hear voices or express unusual beliefs
  4. Collaborative approach to nursing: assessment and care planning

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Feb 25, 2017 | Posted by in NURSING | Comments Off on Working with people who are anxious or low in mood

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