UP FRONT
Vol 56: December • Décembre 1245-1380
New series in CFP
scientific editor
rédacteur scientifique
Nicholas Pimlott MD CCFP
ASSOCIATE Scientific editor
rédacteur scientifique ADJOINT
Roger Ladouceur md msc fcmf
editorial fellow
boursière en rédaction médicale
Jessica Fulton md CCFP
MANAGING EDITOR
RéDACTRICE EN CHEF
Kathryn Harrington
MANUSCRIPt EditorS
réviseurs de manuscrits
Mirjana Macokatic
Tasleen Adatia
contributing editors
collaboratriceS de rédaction
Primrose E. Ketchum ma
Allyn E. Walsh
md CCFP fcfp
Michelle Howard MSc PhD
Ian Cameron MD CCFP
statistical reviewer
analyste statisque
Rahim Moineddin msc phd
manuscript and circulation coordinator
coordonnatrice des manuscrits et de la distribution
Mairi Abbott
Graphics manager
responsable artistique
Deborah Doucette
Graphic designer
Conceptrice graphique
Katherine Aldous
Production coordinator
Coordonnatrice de la production
Yvonne Fernandes
Translation
traduction
Marie Plante
Michel Jobin
Elizabeth Fairley
Advertising and classifieds coordinator
coordonnatrice de la publicité et annonces classées
Beth Carter
Advertising sales
ventes de publicité
Peter Craig (toronto)
Pat Tramley (montrÉal)
Director of Library Services
Directrice des services bibliothécaires
Lynn Dunikowski MLS
associate publisher and Production Manager
éditeur associé et responsable à la production
Peter Thomlison
publisher
Éditeur
David Dehaas
Executive Director and chief executive officer
directeur général et chef de la direction
Calvin Gutkin md ccfp(em) fcfp
Starting this month, Canadian Family Physician will be hosting a new monthly
series by Dr Greg Dubord on cognitive behavioural therapy (CBT) in primary
care. Dr Dubord’s adaptation of orthodox CBT for primary care, which he calls
medical CBT, has proven very popular—since 1999, he has been a regular fixture at Family Medicine Forum, where he has given 35 full-day Mainpro-C
workshops. This “how-to” series is based on Mainpro-C workshops that he
has organized for family physicians over the past year. In these practical
and accessible Praxis articles, Dr Dubord will outline the core principles and
practices of medical CBT for family physicians. The first article in the series,
“Goalification,” can be found on page 1312.
Milk for newborns
The Canadian Paediatric Society1 has recommended pasteurized human milk
for hospitalized sick newborns when their own mothers’ milk is not available.
The statement owns that “Despite advances in infant formulas, human breast
milk provides a bioactive matrix of benefits that cannot be replicated by any
other source of nutrition,” including improved child health and development as
well as improved maternal health. However, it goes on to stipulate that strict
controls must be implemented on how and when donor milk should be used,
and advocates further research into the benefits of banked human breast milk
for preterm infants in intensive care.
Milk donors are screened with the same vigour as blood donors, and pasteurization ensures that the milk is safe. Parents of sick newborns should be
educated by health care providers about the benefits of breast milk; pasteurized human donor milk should only be provided to a baby following informed
consent from a parent or guardian and on the advice of a health care worker.
Ultimately, such choices might not matter in most areas of the country.
The supply of donor breast milk in Canada is limited; there is only 1 human
milk bank in Canada, based in Vancouver, BC, and it cannot meet the needs
of all the babies who could benefit.
—Tasleen Adatia
Reference
1. JH Kim, S Unger; Canadian Paediatric Society. Human milk banking. Paediatr Child Health
2010;15(9):595-8. Available from: www.cps.ca/english/statements/N/N10-01.htm. Accessed
2010 Nov 16.
Canadian Adverse Reaction Newsletter
The latest Canadian Adverse Reaction Newsletter is available online at www.
healthcanada.gc.ca/carn. Topics covered in this issue include the following:
•
•
•
•
•
statins and interstitial lung disease;
potential interference of computed tomography scanning with electronic medical devices;
Red Bull Energy Drink: suspected association with seizure;
new consumer form for reporting adverse reactions; and
quarterly summary of advisories.
To receive this newsletter and health product advisories free by e-mail, join Health
Canada’s MedEffect mailing list. Go to www.healthcanada.gc.ca/medeffect.
Bulletin canadien des effets indésirables
Le numéro le plus récent du Bulletin canadien des effets indésirables est disponsible à www.santecanada.gc.ca/bcei. Dans ce numéro:
• les statines et la pneumopathie interstitielle;
• Interférence potentielle entre la tomodensitométrie et des dispositifs médicaux électroniques;
• Red Bull Energy Drink: lien soupçonné avec une crise d’épilepsie;
• nouveau formulaire de déclaration des effets indésirables par le consommateur; et
• sommaire trimestriel des avis.
Pour recevoir gratuitement par courriel le Bulletin et les Avis sur les produits de
santé; inscrivez-vous à la liste MedEffet. Rendez-vous à l’adresse www.santecanada.
gc.ca/medeffet.
Vol 56: december • décembre 2010 Canadian Family Physician • Le Médecin de famille canadien 1253
Praxis
Part 1. Goalification
Greg Dubord
MD
Our lives are spent either in doing nothing at all, or in
doing nothing to the purpose, or in doing nothing that
we ought to do; we are always complaining our days are
few, and acting as though there would be no end of them.
Seneca (4 BC to 65 AD)
I
magine your practice with fewer complaining patients. Imagine your patients more focused on their
goals than their grievances. Patients begin with complaints, but complaints are just the raw material of goals.
Embedded within every complaint is at least one goal.
Our patients often need help seeing things that way.
Goalification is the term I use to describe the process by which we transform complaints into goals. You
“goalify” complaints by articulating their opposites. Put
mathematically:
Goal = 1/complaint
You’re on an antonym quest. The International
Classification of Diseases helps us with diagnosis and
Roget’s Thesaurus helps us goalify. Here are some examples:
Complaint
Possible antonyms (goals)
Depression Happiness, contentment, enthusiasm, satisfaction, joy
Anxiety
Calmness, serenity, ease, peace, tranquility
Social
anxiety
Extroversion, confidence, social comfort, social
ease, participation
The core concern is that complaining leads nowhere. If
you allow your patients to complain for 10 years—all the
while providing exemplary empathy—they’ll no doubt
feel “understood,” but there’s no assurance that they’ll
have solved their problems. A decade of dedication to
goal-focused behaviour doesn’t guarantee results either,
but the odds are immeasurably higher.
There’s a standard script in primary care: patient
complains  doctor draws empathy into syringe  doctor administers bolus of empathy  patient feels good
and thanks doctor  patient returns to life, changing
nothing  empathy buzz wears off  patient books
another appointment.
You might have learned that lengthy supportive listening is the sine qua non of caring. But science suggests there’s a U-shaped curve: outcome is optimized
with a midrange of empathy. Overemphasis on supportive listening sometimes creates an “empathy addict”
with a stagnant life. It’s tough to goalify unless you prioritize being helpful over being thought nice and polite.
In the following dialogue I interrupt in the service of
redirecting the patient’s energies:
1312 Cognitive Behavioural Therapy Series
Pt: I’m so depressed [elaborates].
Dr: [Accurate but brief empathy statement, then …] It sounds
like your goal is the opposite of that. I wonder what that
would be? Maybe happiness?
Pt: [Slight pause, then resumption of complaining] Yeah, sure
… but I’m so depressed. I’m so depressed.
Dr: [Accurate but brief empathy statement, then …] Sorry to
interrupt, but it sounds like you’re saying you have a goal of
making yourself happier—do I have that right?
Pt: [Slightly longer pause, then resumption of bitter complaining] Yeah, but I’m so depressed. I’m so depressed.
Dr: Wow! I hear the passion in your voice! You’re fed up with
being depressed, aren’t you? It sounds like you really want the
opposite of that—that you really want to increase your happiness! It sounds like you’re ready to truly commit to doing the
things required to make yourself happier. Have I got that right?
Pt: Yeah, it would be nice to be happier. But how do I do that?
If there’s patient buy-in at that point, the patient is
directed toward a review of the things she or he is willing
to do to make progress toward the goal (future articles
in this series will elaborate on this). There’s sometimes
an opportunity to highlight—in the nicest way possible—
that except in the most idealistic New Age philosophy,
simply desiring an outcome is no guarantee that it will
“manifest.” Put more diplomatically, downstream from the
same old behaviour is the same old mood. If the patient
wants a new mood, the patient will likely have to behave
differently. You have to earn your mood.
Goalification is particularly appropriate for chronic
complainers. It assumes the following:
• you’ve listened enough to understand the problem—and
satisfactorily conveyed that understanding to the patient;
• you’ve earned a relatively strong doctor-patient relationship; and
• you’re carefully attuned to the patient’s responses as
you goalify.
Goalification’s goals include increased assurance that
patient and physician energies are directed properly,
improved outcomes, and prevention of physician burnout.
In summary:
Complaints  Goalification  Goals
Dr Dubord teaches cognitive behavioural therapy (CBT) for the Department of Psychiatry
at the University of Toronto. In this series of Praxis articles, he outlines the core principles
and practices of medical CBT, his adaptation of orthodox CBT for primary care.
Acknowledgment
I thank the following CBT Whistler 2010 participants for their helpful critique of this
paper: Dr Graham Mansell, Dr Desmond Konway, Dr Susan Burgess, Dr Greg Cully,
and Dr Raj Rampersaud.
Correspondence
Greg Dubord, e-mail [email protected]
Canadian Family Physician • Le Médecin de famille canadien Vol 56: DECEMBER • DÉCEMBRE 2010
Next month: Scalification
Praxis
Part 1. Goalification
Greg Dubord
MD
Our lives are spent either in doing nothing at all, or in
doing nothing to the purpose, or in doing nothing that
we ought to do; we are always complaining our days are
few, and acting as though there would be no end of them.
Seneca (4 BC to 65 AD)
I
magine your practice with fewer complaining patients. Imagine your patients more focused on their
goals than their grievances. Patients begin with complaints, but complaints are just the raw material of goals.
Embedded within every complaint is at least one goal.
Our patients often need help seeing things that way.
Goalification is the term I use to describe the process by which we transform complaints into goals. You
“goalify” complaints by articulating their opposites. Put
mathematically:
Goal = 1/complaint
You’re on an antonym quest. The International
Classification of Diseases helps us with diagnosis and
Roget’s Thesaurus helps us goalify. Here are some examples:
Complaint
Possible antonyms (goals)
Depression Happiness, contentment, enthusiasm, satisfaction, joy
Anxiety
Calmness, serenity, ease, peace, tranquility
Social
anxiety
Extroversion, confidence, social comfort, social
ease, participation
The core concern is that complaining leads nowhere. If
you allow your patients to complain for 10 years—all the
while providing exemplary empathy—they’ll no doubt
feel “understood,” but there’s no assurance that they’ll
have solved their problems. A decade of dedication to
goal-focused behaviour doesn’t guarantee results either,
but the odds are immeasurably higher.
There’s a standard script in primary care: patient
complains  doctor draws empathy into syringe  doctor administers bolus of empathy  patient feels good
and thanks doctor  patient returns to life, changing
nothing  empathy buzz wears off  patient books
another appointment.
You might have learned that lengthy supportive listening is the sine qua non of caring. But science suggests there’s a U-shaped curve: outcome is optimized
with a midrange of empathy. Overemphasis on supportive listening sometimes creates an “empathy addict”
with a stagnant life. It’s tough to goalify unless you prioritize being helpful over being thought nice and polite.
In the following dialogue I interrupt in the service of
redirecting the patient’s energies:
1312 Cognitive Behavioural Therapy Series
Pt: I’m so depressed [elaborates].
Dr: [Accurate but brief empathy statement, then …] It sounds
like your goal is the opposite of that. I wonder what that
would be? Maybe happiness?
Pt: [Slight pause, then resumption of complaining] Yeah, sure
… but I’m so depressed. I’m so depressed.
Dr: [Accurate but brief empathy statement, then …] Sorry to
interrupt, but it sounds like you’re saying you have a goal of
making yourself happier—do I have that right?
Pt: [Slightly longer pause, then resumption of bitter complaining] Yeah, but I’m so depressed. I’m so depressed.
Dr: Wow! I hear the passion in your voice! You’re fed up with
being depressed, aren’t you? It sounds like you really want the
opposite of that—that you really want to increase your happiness! It sounds like you’re ready to truly commit to doing the
things required to make yourself happier. Have I got that right?
Pt: Yeah, it would be nice to be happier. But how do I do that?
If there’s patient buy-in at that point, the patient is
directed toward a review of the things she or he is willing
to do to make progress toward the goal (future articles
in this series will elaborate on this). There’s sometimes
an opportunity to highlight—in the nicest way possible—
that except in the most idealistic New Age philosophy,
simply desiring an outcome is no guarantee that it will
“manifest.” Put more diplomatically, downstream from the
same old behaviour is the same old mood. If the patient
wants a new mood, the patient will likely have to behave
differently. You have to earn your mood.
Goalification is particularly appropriate for chronic
complainers. It assumes the following:
• you’ve listened enough to understand the problem—and
satisfactorily conveyed that understanding to the patient;
• you’ve earned a relatively strong doctor-patient relationship; and
• you’re carefully attuned to the patient’s responses as
you goalify.
Goalification’s goals include increased assurance that
patient and physician energies are directed properly,
improved outcomes, and prevention of physician burnout.
In summary:
Complaints  Goalification  Goals
Dr Dubord teaches cognitive behavioural therapy (CBT) for the Department of Psychiatry
at the University of Toronto. In this series of Praxis articles, he outlines the core principles
and practices of medical CBT, his adaptation of orthodox CBT for primary care.
Acknowledgment
I thank the following CBT Whistler 2010 participants for their helpful critique of this
paper: Dr Graham Mansell, Dr Desmond Konway, Dr Susan Burgess, Dr Greg Cully,
and Dr Raj Rampersaud.
Correspondence
Greg Dubord, e-mail [email protected]
Canadian Family Physician • Le Médecin de famille canadien Vol 56: DECEMBER • DÉCEMBRE 2010
Next month: Scalification
Praxis | Cognitive Behavioural Therapy Series
Part 2. Scalification
Greg Dubord
MD
O
nce a complaint (eg, depression, anxiety, loneliness)
has been “goalified”1 (eg, happiness, calmness, community), the next step is “scalification.”
Scalification is most easily defined with an example:
Pt: Doc, I’m so depressed [elaborates].
Dr: [Accurate empathic statement, then goalifying] It
sounds like your goal is to make yourself happier. Have
I got that right?
Pt: [Responding rapidly] Yes, I guess you could say that.
Dr: [Scalifying] OK, well let’s imagine a 0-to-10 scale of
happiness, where 0 was your most depressed, and 10 was
your happiest. Where are you along that scale today?
Accountability is the primary purpose of scalifying (eg,
patient-to-self, patient-to-doctor, and doctor-to-patient).
The main application of scalification is for those psychological interventions with a medium level of formality—
not likely to be a “one-off,” but not likely to be full-on
“psychotherapy” either. One-offs don’t need scales, and
formal psychotherapy lacks credibility without more formal psychometry (eg, Beck Depression Inventory, Beck
Anxiety Inventory).
Scalification continues with a “why-not-worse” question to reinforce the patient’s locus of control:
Dr: [Empathy, then …] You say 3. What are some of things
you’re doing to keep it from being a 2?
The final component in scalifying is a “how-makebetter” question:
Dr: What are you willing to commit to [or experiment with]
doing to try to make it a 4 between now and our next
appointment?
The “how-make-better” question might have to be
repeated: it’s not uncommon for the patient to slip back
into “complaint mode” at this time. Sometimes even regoalifying is required:
Dr: Sorry to interrupt, but when you say you’re so depressed,
you’re also saying that happiness is your goal, right?
The doctor ends with a behavioural prescription—which
is ideally recorded in the chart.
An excellent opening question on follow-up is as
follows:
Dr: Last time we agreed that you have a goal of happiness,
and you said you were 3 on a 0-to-10 scale. You were
doing A and B to keep it from getting worse, and said
you’d try doing C and D to try to make it better. Where
are you on our happiness scale today?
If there was good adherence and a good outcome,
make sure you point out the correlation. If the link
seems causal, say so. Many chronic patients have erroneously concluded that mood is randomly determined.
To us causal connections are obvious, but to those with
“learned helplessness” they are not.
In the common scenario of poor adherence and a
poor outcome, linger awhile. It’s vitally important that
patients learn from natural consequences. Consider asking a question like “What do you make of that?” and
pausing. Diving in too early with anesthetizing empathy
can impair learning, and in the long run can be iatrogenic (this issue will be addressed in greater depth in a
future article).
In the unfortunate scenario of good adherence and
poor outcome, begin with a good dose of empathy.
Emphasize that efforts are essential even without a
100% guarantee of mood improvement. Discuss lag
effects (if appropriate). Collaboratively explore whether
another experiment with the same behavioural prescription is warranted, and tweak as required.
Scalification is both a measurement tool and an intervention with an important role in psychological situations with medium formality. Dr Dubord teaches cognitive behavioural therapy (CBT) for the Department
of Psychiatry at the University of Toronto. In this series of Praxis articles, he
outlines the core principles and practices of medical CBT, his adaptation of
orthodox CBT for primary care.
Acknowledgment
I thank the following CBT Blue 2010 participants for their helpful critique of this
paper: Dr Chuck Adamson, Dr Ray Bouchard, and Dr Sandra Wismer.
Correspondence
Greg Dubord, e-mail [email protected]
Reference
1. Dubord G. Part 1. Goalification. Can Fam Physician 2010;56:1312.
Next month: The Reward Chart
54 Canadian Family Physician • Le Médecin de famille canadien
| Vol 57: January • JaNVIER 2011
Cognitive Behavioural Therapy Series |
Praxis
Part 3. The reward chart
Greg Dubord
MD
In medical CBT there are 3 levels of formality:
1. Goalification only (see December 2010 article1)
2. Goalification and scalification (see January 2011 article2)
3. Goalification, scalification, and reward charting (this month’s topic)
Although many factors determine which level of formality is most sensible for a given patient, in the real
world time is often the overriding issue. How long do
you have with Mrs Jones today?
• 1 to 2 minutes  goalify only
• 4 to 5 minutes  goalify and scalify
• 10 to 15 minutes today, and likely the same several
times again  goalify, scalify, and reward chart
A basic reward chart looks like this:
EFFORTS AND REWARDS
Date 1
Date 2
Date 3
Date 4
Efforts
• Fixitol 20 mg daily
• Exercise
• Social efforts
• Sleep habits
Rewards
• Happiness (1-10)
The term reward chart implies that patients are to a
fair extent responsible for creating their own rewards (eg,
moods). A precise a priori determination of the extent to
which this is true for a given patient is impossible—it’s
the old nature-versus-nurture debate—but fortunately
most patients have more control than they believe.
In the medical CBT paradigm, adhering to a prescribed
medication regimen is but one effort a patient can choose
to commit to. Other efforts might include more regular exercise, increased socialization, and improved sleep
habits. This is not to discount the role of medication—we
know from research, practice, and sometimes personal
experience that medication can be very helpful—but we
must also emphasize other interventions.
Tips
•
First, explain the effort-reward paradigm. Explanations
are particularly needed for biological reductionist
patients (ie, those who fatalistically believe that all is
predetermined by neurochemistry). Encourage these
patients to “experiment” with adjunctive interventions
“in the meantime” (ie, until their medication kicks in).
• Next, complete the rewards section. Rewards are
the antonyms of the control presenting complaints.1
Common examples are happiness for depression;
sense of belonging for loneliness; and calmness for
anxiety. All rewards should be scalified (eg, happiness
on a 1 to 10 scale).2 Caution: patients with more than
2 or 3 goals will likely lose focus.
• Next, fill in the efforts section. Stick with tried-and-true
efforts like medication adherence, physical exercise,
social or nutrition efforts, and improved sleep regularity. Consider splitting “effort cells” diagonally. Enter the
negotiated effort in the top left, and enter the patient
follow-through in the bottom right. In the example below,
the agreed-upon exercise effort was twice per week, but
on follow-up the patient had exceeded expectations:
Exercise
2/7
3/7
Openly share the reward chart with the patient. In the
ideal world, the patient becomes the chart’s steward,
maintaining his or her own copy at home.
• Efficient follow-up begins with the reward scales.
•
Dr: Please tell me, Mrs Jones, what rewards have you gained on our chart
here? [demonstrating chart] Last week you were a “3” on the happiness scale. Where are you today? [then review efforts] Last time we’d
agreed to several efforts for those rewards. For our first effort—exercise—your target was twice a week. How was your follow-through?
•
Take ample time to highlight the links between efforts
and rewards. To us the links might be obvious, but to
our patients with learned helplessness they are not.
• If good efforts were poorly rewarded, put on your
coach’s jersey. Talk about “mood lag”: some efforts (eg,
taking antidepressants) might not deliver results for
many weeks. Insist on another round or two of experimentation with current efforts. Perhaps tweak some
items. But beware: if a patient is chronic (eg, dysthymic), resist taking over as mood steward.
• If things are going well, curb your enthusiasm for adding
more items (efforts or rewards). Go slowly and steadily.
You might have a sizeable healing aura. Sadly, patients
seeing you 10 minutes a week can only experience that
aura 10/(60 × 24 ×7) = 0.1% of the time. The reward chart
reinforces for patients the fact that they must invest that
other 99.9% of their lives wisely. Dr Dubord teaches cognitive behavioural therapy (CBT) for the Department of Psychiatry at
the University of Toronto. In this series of Praxis articles, he outlines the core principles and
practices of medical CBT, his adaptation of orthodox CBT for primary care.
Acknowledgment
I thank Drs Leo Lanoie and Abraham Vermeullen for their helpful critique of this paper.
Correspondence
Greg Dubord, e-mail [email protected]
References
1. Dubord G. Part 1. Goalification. Can Fam Physician 2010;56:1312.
2. Dubord G. Part 2. Scalification. Can Fam Physician 2011;57:54.
Vol 57: february • février 2011
Next month: Maturity coaching
| Canadian Family Physician
•
Le Médecin de famille canadien 201