This document provides an overview of a session on combining the biopsychosocial and CBT models in practice. It begins with welcoming the participants and providing information on Division 38 of the APA and its website. It then outlines two case studies, one on a patient with heart failure and another with generalized anxiety and irritable bowel syndrome. The document discusses the biopsychosocial model and how CBT can integrate factors from this model. It provides objectives for the session and discusses caveats before concluding with introductions of the presenters.

1. Welcome!
This session sponsored by APA Division 38: Health Psychology
For information about D38’s benefits and services for SCIENTISTS and
PRACTIONERS across the professional life span,
Please visit our web site: www.health-psych.org
Combining the Biopsychosocial and CBT Models in Practice
Jared L. Skillings, PhD, ABPP
Kevin D. Arnold, PhD, ABPP

3. Case Study: Biopsychosocial Model
• Patient hospitalized with AHF; Hx of SA,
family conflict, & non-adherence
§ Cardiologist writes “prescription” for SA sobriety.
• Patient is re-hospitalized after 5 weeks.
§ Says to the physician: “Doc, I followed your
directions. Are you going to let me die now?”
• Question - Should this patient be selected for
an LVAD (i.e. mechanical heart pump)?

5. Case Study: CBT
• Generalized Anxiety and
Irritable Bowel Syndrome
§ Presentation with Anxiety
in Social, Travel, Intimacy
§ History of Exposure to
Toxic Stress and
Unpredictable Hostility and
Disregard from Parents
§ IBS had Intermittently
Become Acutely Severe
§ How Does the IBS Play
into the GAD?

6. BPS Model of IBS
Additional Factors from a
CBT Model
Cognitive
• Risk Appraisals
• Catastrophic Thinking
• Anxiety-based Problem
Solving
• Mind Reading
Emotional
• Lack of Skills to Tolerate
Distress from Anxiety
• Embarrassment
Behavioral
• EDBs—Avoidance of Risk
Environments, Safety
Planning, Social Isolation
Mayer EA. Emerging disease model for functional gastrointestinal disorders. Am J Med 1999;107(5A):13S.

7. Introductions
This session sponsored by APA Division 38: Health Psychology
For information about D38’s benefits and services for SCIENTISTS and
PRACTIONERS across the professional life span,
Please visit our web site: www.health-psych.org
Combining the Biopsychosocial and CBT Models in Practice
Jared L. Skillings, PhD, ABPP
Kevin D. Arnold, PhD, ABPP

8. Objectives
§ Identify 4 aspects of biopsychosocial functioning
that should be reviewed in every patient/client
encounter.
§ Identify 3 places in the biopsychosocial continuum
of care to utilize CBT methods.

9. 9

10. Caveats
• This presentation will not make you a Clinical
Health Psychologist or a Cognitive Behavioral
Psychologist.

12. CRSPPP
• Clinical Health Psychology:
§ http://www.apa.org/ed/graduate/specialize/health.aspx
• Cognitive Behavioral Psychology:
§ http://www.apa.org/ed/graduate/specialize/behav.aspx

13. Biomedical, Psychogenic, and
Sociocultural Models
Jared L. Skillings, PhD, ABPP
Spectrum Health System; Grand Rapids, MI

14. Biomedical Model

15. Leading causes of death: USA, 1958-2010
15

16. 16

17. Real-life Examples?

21. Total health care investment

24. Part of the Problem?

27. Recent Biomedical Example

29. 29

30. Psychogenic models

31. http://www.nature.com/nm/journal/v16/n7/fig_tab/nm0710-756_F1.html

35. 35

39. REBT Model

41. Biobehavioral Treatment Markers
C.
McGrath,
et
al.,
(2013).
JAMA
Psychiatry,70(8),
821-­‐829
Average effect size = 1.43
Low Insula: Rem to CBT, NR to Drug
High Insula: Rem to Drug, NR to CBT
Remit when matched to brain type
No demographic, clinical correlate of PET

42. Biobehavioral Treatment Markers
C.
McGrath,
et
al.,
(2013).
JAMA
Psychiatry,70(8),
821-­‐829

43. Social Determinants
Of Health
Jared L. Skillings, PhD, ABPP
Spectrum Health System; Grand Rapids, MI

45. Healthy People 2020

48. Biopsychosocial
Model
Jared L. Skillings, PhD, ABPP
Spectrum Health System; Grand Rapids, MI

50. 50

51. Biopsychosocial Model
• Focus = holistic well-being
• Conceptually integrative
§ Mind and body are necessarily linked.
• Interventions may be biomedical,
psychological, familial, environmental, or
cultural.
• Prevention is an important focus.

53. http://www.cdc.gov/pcd/issues/2012/11_0324.htm

54. Integrating Biopsychosocial
Conceptualization into CBT
Kevin D. Arnold, PhD, ABPP
The Center for Cognitive and Behavioral Therapy
Columbus, Ohio
www.ccbtcolumbus.com

55. Why CBT without BPS is Problematic
• Health-related behaviors are
learned within contexts.
• Contexts:
§ Situations in which Learning
occurs
§ Situations that trigger learned
reactions
• Contexts incorporate all
three BPS spheres:
1. Biological
§ Internal biological system
operations
§ Internal sensations and capacity
of biological systems to adapt

56. 1. Biological
§ Internal biological system
operations
§ Internal sensations and
capacity of biological
systems to adapt
Why CBT without BPS is Problematic

57. 2. Psychological
§ Previous Learning Reactions
to Triggers
§ Different Reactions have
Different Likelihoods
§ Automatic Meaning Making
and Inferences, and
§ Automatic Thoughts
(Catastrophizing,
Discounting, Mind Reading,
All-or-None, etc.)
Why CBT without BPS is Problematic

58. 3. Social
§ Relationships provide Praise,
Attention and/ or
Punishment,
§ Relationship Systems create
Coping Resources, and
§ Learning of Relationships as
sources of Reward or No-
Reward for Certain Behaviors
Why CBT without BPS is Problematic

59. How CBT Relies on the BPS Model
• Ideas and Automatic Inferences about
Risk are Learned within BPS
§ Ideas which Occur or Don’t Occur based
on Triggers and Learning History Set-up
Automatically Thinking Certain Ideas AND
Not Other Ideas
§ Biological: Observing and Interpreting
Risks about learned physiologic
responses (increase in HR, localized pain)
§ Psychological: Awareness of Emotions
Validates Ideas and Automatic Inferences
(rather than all the evidence from reality)
§ Social: Ideas and Inferences about Risk
are Learned through Modeling of Others
Ideas and Social Rewards for Certain
Ideas vs. More Realistic Thoughts
(including “negative attention)

60. CBT and BPS Integration
• Case Conceptualization: Assess
Current Factors
§ Individual Behavioral and Cognitive
Contributions
• Existing Behavior Patterns/Habits,
EDBs
• Current Automatic Thoughts and
Beliefs/Meanings
§ Biomedical and Physical Health
Contributions
• Current Physical Disorders/Diseases,
Learned Physiologic Reactions to
Certain Triggers, Neuro-cognitive
Abilities and Decrements
§ Past and Current Social Contributions
• Family System, Social Network, Socio-
vocational Relationships, Community
Culture

61. CBT and BPS Integration
• Case Conceptualization: Integrate
Learning with Current Factors
§ Individual Behavioral and
Cognitive Contributions
• Existing Learned Triggers/
Associations and Various Learned
Expectations for Rewards
Depending on Reactions
§ Bio-medical and Physical Health
Contributions
• Experience of Physical Health
(vs. Knowledge) Can Be Rewards
and Punishment
§ Past and Current Social
Contributions
• How have Others in the Past and
Currently Reacted to Both Bio-
medical and Psychological Health
Status (Attention, Praise,
Criticism, Withdrawal, etc.)

62. CBT and BPS Integration
• Case Conceptualization:
Motivation and Interest to
Change
• SOC and MI
• Capacity to Take Control of 1)
Rewards Received from Self and
Others, 2) Exposure to Triggers
for Ideas, 3) Exposure to
Behavioral Reaction Triggers
• Capacity to Accept Chronic
States vs. EDBs
• Capacity to Self-Manage Physical
Experiences (Relaxation,
Meditation, Mindfulness)
• Willingness of Social Systems to
Change vs. Perpetuate
Homeostatic Drive

63. Targets of Change within CBT
• Bio-Medical and Behavioral Activation
Techniques
§ Compliance with medical treatments
§ Access to Appropriate Care and
Procedures
• Psychological
§ Change High-Risk Behaviors
§ Modification of Automatic Thoughts
§ Development or Strengthening of
Healthy Behaviors
§ Overcome Avoidance Behaviors
§ Improve Reality-based Conceptual
Understanding
• Social
§ Modification of Family and Social
Structures and Roles to Support Change
§ Modification of Patient’s Understanding
of Two and Three Person Interactions/
Relationships

64. Back to the Case of IBS and GAD
• How Context Predicts
§ Interpretation of Medical
Interactions and Treatment
Compliance
§ Risk Appraisal re: Bio-Medical
Symptoms and Social/ Personal
Risk
§ How Treatment Balances
Validation with Exposure Therapy
• Anxiety and IBS Sx
Management

65. Future Course of Action: CBT and Public Health
• A Key Goal of Public Health: Prevention
• What are the Three Levels of Prevention?
§ Primary, Secondary, Tertiary

66. Levels of Prevention

67. Future Course of Action: CBT and Public Health
• A Key Goal of Public Health: Prevention
• What are the Three Levels of Prevention
§ Primary, Secondary, Tertiary
• How CBT can Apply to Prevention?

68. Future Course of Action: CBT and Public Health
• Examples of How CBT can Contribute to
Public Health Goals
§ Targets for Primary and Secondary Prevention
CBT Efforts
• CBT and PCPs for Primary Prevention (Pediatrics)
• CBT and PCPs for Secondary Prevention
(Pediatrics and Family Physicians/IMs)
§ Tertiary Prevention: Disease Management and
Improved Daily Functioning and QOL

69. Model for Integrating
Medicine and Psychology
Jared L. Skillings, PhD, ABPP
Spectrum Health System; Grand Rapids, MI

70. MI-MAP
• Purpose: To make “psychosocial factors
easier yet more comprehensive for
physicians, nurses, health psychologists,
general psychologists, and social workers.”
Boyer, B. (2008). Chapter 1: Theoretical Models in Health Psychology and the Model for Integrating Medicine and Psychology. In
B. Boyer & M. Paharia (2008). Comprehensive Handbook of Clinical Health Psychology. (pp. 3-30).

71. Disease Factors
• Disease onset
§ Symptomatic vs. latent
§ Traumatic (cause or prognosis)
• Disease progression
§ Acute vs. Chronic
§ Episodic vs. Constant
• Types of symptoms
§ Functional interference
§ Visible to others
§ Contagious to others

72. Treatment Regimen
• Complexity
• Intrusiveness
• Accessibility
• Cost
• Side effects

73. Individual (patient) factors
• Intelligence
• Information
• Literacy and Health literacy)
• Culture
• Trust
• Health Beliefs
• Coping
• Social Support

74. Co-occurring psychopathology
• Depressive Disorders
• Anxiety Disorders
• Substance Use & addiction
• Cognitive impairment & dementia
• Severe mental illness
• Personality Disorders
• Somatoform Disorders
• ADHD, LD, Autism

75. Case Example
“Gail”
Jared L. Skillings, PhD, ABPP
Spectrum Health System; Grand Rapids, MI

76. Demographics & Social History
• 61 year-old, Caucasian, married female.
• Social Hx was noncontributory.
§ Supportive family. Stable job.
• No substance abuse or drug use.

77. 77

78. 78

79. Psychiatric History
• Clear mental status
• Previous diagnoses of mild depression & anxiety.
• Treatment:
§ 2 psychotherapy bouts years ago (anxiety &
behavioral pain management)
§ PSY meds: Effexor in past

80. Medical history
• Current diagnoses: Hyperlipidemia, GERD, OSA,
chronic lower back pain
• Historical diagnoses: migraine headaches, chronic
facial pain, cystic acne
• Surgical history: bladder suspension, colonoscopy &
pollup removal
• Treatment: Routine PCP visits, CPAP use, statin med,
occassional pain med

81. Wound History
• Started as insect bite 2½ years ago.
• Pt. picked and scratched until wound formed.
• Initiated medical treatment after 1½ years.
• CA, derm, ID, and metabolic causes ruled out.

84. TREATMENT
1. Psychotropic medication
2. Psychotherapy (which kind?)
3. Deep brain stimulation surgery

85. Course of Treatment
• Referred to psychiatry. OCD correctly diagnosed.
Started Effexor 225mg daily.
• Referred to psychology for CBT (July 2012).
85

87. Previous psychotherapy
• Psychological support
• Stimulus control techniques alone
§ Limit and control times and amount of
touching.

88. CBT case conceptualization
• Precipitating factor(s)?
§ Insect bite
§ Hx of cystic acne
• Perpetuating factor(s)?
§ Lack of education / denial
§ Punishment of medical Tx for dermatology
needs
§ Negative reinforcement

89. Habit Reversal Training (HRT)
1. Inconvenience review
2. Awareness training
3. Competing response training
4. Utilization of social support
5. Generalization
Azrin, N. H., & Nunn, G. R. (1973). Habit reversal: A method of eliminating nervous tics and habits. Behaviour Research and Therapy, 11, 619–628.
Teng, E.J., Woods, D.W., Twohig, M.P. (2005). Habit reversal as a treatment for chronic skin picking. Behavior Modification, 30 (4), 411-422.

90. Gail’s Treatment Process
• 8 CBT (primarily ERP) sessions over 6 months.
• Effexor 225mg daily
• CBT Interventions:
• Identification of triggers
• Exposure w/ Response Prevention
• Cognitive restructuring & education
• Habit reversal training

91. Outcome = Wound Measurements
• Worst (May 2012)
• 3½” x 2½” x ¾”
• Best (July 2014)
• 1” x ¾” x ¾”
91

92. 92

93. 93

94. Welcome!
This session sponsored by APA Division 38: Health Psychology
For information about D38’s benefits and services for SCIENTISTS and
PRACTIONERS across the professional life span,
Please visit our web site: www.health-psych.org
Combining the Biopsychosocial and CBT Models in Practice
Jared L. Skillings, PhD, ABPP
Kevin D. Arnold, PhD, ABPP