Psychotherapy

CBT for specific issues?

CBT for anxiety Behavioural experiments follow construction of hypothesis about symptoms e.g.,, a hypothesis that 'when one has a panic attack he will not get suffocated even if he is not hyperventilating or holding tight to his chest' is tested through homework by the patient conducting an experiment of not holding tight and not hyperventilating and reporting the event in next session. This helps to: 1. Establish that a feared catastrophe will not happen; 2. Discover the importance of maintaining factors; 3. Discover the importance of negative thinking; 4. Find out whether an alternative strategy will be of any value; and 5. Generate evidence for a non-disease-based explanation Imagery modification: Visual imagery of threatening stimuli can be modified in those with anxiety. Stages of guided discovery Stage 1: Asking informal questions Delineate patient's concerns Stage 2: Listening To be clear about exact issues Stage 3: Summarising To demonstrate understanding and to revise Stage 4: Synthesizing / analytical questions 'How does all the information discussed fit with your idea that you are a failure?' © SPMM Course 22 Cognitive restructuring refers to modifying or 'reframing' one's thinking style to see a different, non-anxiety inducing perspective. Dropping Safety-Seeking Behaviors. Safety behaviours such as checking, reassurance seeking—maintain health anxiety. Patients can test out the effects of these behaviors for themselves by conducting an alternating treatment experiment. This experiment involves, first, increasing the target behavior for a day—such as bodily checking and information seeking—and, second, monitoring anxiety, bodily symptoms, and strength of belief at regular intervals. On the next day, the patient has to ban completely carrying out the target behaviour, but once again, anxiety, symptoms, and strength of belief are monitored at intervals. The resulting data is reviewed and graphed at the next session. CBT for OCD Thought stopping is a behavioural technique in OCD. Here the patient shouts 'stop' or applies an aversive stimulus (such as pressing his nails) to counteract the obsessional preoccupation. Thought postponement (OCD) refers to postponing the thought until a specified time and not to delaying it until then to gain control. Exposure and response prevention for OCD refers to a paradigm similar to systematic desensitization where the hierarchy of obsession provoking situations is created and exposed to while preventing any compulsions or responses being carried out. CBT for hypochondriasis / health anxiety: Self-monitoring by using health-anxious thoughts diary. An inverted pyramid technique is helpful for addressing overperception of risk. The patient is asked to estimate the current number of people with a particular symptom (i.e., those who have it today), the number for whom it persists, the number who consult their doctors, the number who are told they need tests, the number who are told the problem is serious, and the number who are not successfully treated. Selective Physical Attention Experiments: Patients are asked to focus on a specific body part for several minutes (one that is not a current cause for health anxiety); after which, they are asked to describe any bodily sensations they notice. Most patients will detect sensations that they were unaware of before the experiment—for example, tightness in throat, tingling in feet. This exercise is helpful as a demonstration of the effects of symptom monitoring and bodily checking.

Therapies based on conditioning

Systematic Desensitization (Wolpe): This is based on the behavioral principle of counterconditioning (i.e. gradual approach of feared situation in a psychophysiological state that inhibits anxiety leads to reduction of anxiety response.) and reciprocal inhibition (i.e. when anxiety and a relaxed state are co-existent, then anxiety reduces). Systematic desensitization consists of three steps: - Relaxation Training - Constructing a Hierarchy of Anxieties - Desensitization of the stimulus The patient is exposed to a graded hierarchy of anxiety-provoking situations in stepwise fashion. Example: a young woman with a spider phobia is first taught relaxation techniques (such as visualisation), then is exposed to experiences starting from the lowest level of her hierarchy of anxieties (such as going to the cellar where there is the potential to come across a spider), going up the ladder to the highest (for example handling a spider). Several concepts related to systematic desensitization are employed in behavioural therapies. - Relaxation produces physiological effects opposite to those of anxiety. In progressive relaxation (Jacobson) patients relax muscle groups in a fixed order starting from small muscle groups working upwards. - In mental imagery, patients are asked to imagine themselves in a place associated with pleasant relaxed memories. - In graded exposure therapy, relaxation training is not involved, and treatment is carried out in a real-life context though in a hierarchical fashion. - Autogenic training: a method of self-suggestion whereby the subject directs his/her attention to specific bodily areas whilst carrying out a relaxation exercise - Applied tension: a technique that is the opposite of relaxation is used to counteract the fainting response (for example in injection phobias) Flooding: In flooding based therapy, real life (in vivo) exposure happens without any hierarchy: the anxiety is not avoided but tackled head-on! Escaping from an anxiety-provoking experience, in fact, reinforces the anxiety through avoidance conditioning; in flooding this conditioning is targeted. The success of flooding depends on exposing patients for a reasonable duration until mastery and calm composure are gained. Premature withdrawal will reinforce the avoidance. In implosion (in vitro) or imaginal flooding, the phobic situation is confronted through imagination, not in real life. Flooding is contraindicated in those with poor stress tolerance or cardiac morbidity that may cause ischemia. Massed Negative Practice: frequently used in tic disorder, when the patient is asked to deliberately perform the tic movement for specified periods of time, interspersed with brief periods of rest. Habit Reversal Training: useful for OCD and tic disorders, consisting of: Awareness training: becoming aware of what stimuli/situations provoke the behaviour Competing response training: teaching responses that counteract the behaviour (e.g., in forearm flexion, the patient practices forearm extension) Contingency management: positive reinforcement for the desirable behaviour Relaxation training Generalisation training: once one component has been mastered; this is generalised to other problem behaviours. Modelling: In participant modeling, patients learn a new behavior by imitation, primarily by observation, without having to perform the behavior until they feel ready. This is useful when treating phobic children. A variant of the procedure is called behaviour rehearsal; wherein real-life problems are acted out under a therapist's observation or direction. Biofeedback: Involuntary autonomic nervous system can be conditioned by the use of appropriate feedback - this is the principle behind biofeedback therapy (Miller). Autonomic functions conditioned include skin temperature, electrical conductivity, muscle tension, blood pressure, respiratory rate and heart rate. It is claimed that various psychosomatic conditions including migraines, asthma, hypertension and angina can be addressed using this technique. Social skills training (SST): SST employs a multitude of learning principles to aid in recovery and rehabilitation of long-term serious mental illnesses such as schizophrenia. Following the framework described by Bellack and Mueser (primarily employed in rehabilitation of patients with schizophrenia), there are three forms of social skills training: 1. The basic model: here complex social repertoires are broken down into simpler steps, subjected to corrective learning, practiced through role playing and applied in natural settings. 2. The social problem-solving model: This focuses on improving impairments in information processing that are assumed to be the cause of social skills deficits. The model targets domains needing changes including medication and symptom management, recreation, basic conversation, and self-care. © SPMM Course 18 3. The cognitive remediation model: Here the corrective learning process begins by targeting more fundamental cognitive impairments, like attention or planning. The assumption is that if the underlying cognitive impairment can be improved, this learning will be transferred to support more complex cognitive processes, and the traditional social skills models can be better learned and generalized in the community.

Types of group therapy (1)?

According to the objectives and degree of leadership: 1. Highly specific target oriented groups include structured groups for drug use or alcohol use, activity groups like occupational therapy groups, etc. These groups have a high level of leader input. 2. Psychodrama, music therapy, systems-centred groups are some less specific therapies but are highly directed by the leader or therapist. 3. Problem-solving therapy and psychoeducational groups are highly specific but have a low level of therapist activity. 4. Support groups, art therapy, interpersonal therapy and groups like Tavistock model analytic groups have a low level of leader activity and have low specificity with respect to treatment goals. According to the membership: © SPMM Course 25 1. Homogeneous groups include members who are comparable in age, diagnosis, background, etc. 2. Heterogenous groups include people of varying categories. 3. Closed groups have a fixed number and composition of patients. If any group member leaves, no new members are included. 4. In open groups no fixed limit exists for number of members; membership is more democratic, and new members can come in whenever someone leaves. According to the mode of therapy: 1. Activity groups- used for patients who are unsuitable for other group activities. Focuses may be art, computing and gardening. It is mainly used in LD, chronic psychosis, and other disorders with functional impairment. 2. Support groups-peer support in LD, chronic illness and also for those caring for others. 3. Problem-focused groups-alcohol dependence, drug dependency, sexual deviancy 4. Psychodynamic groups-Aim of lasting change through exploratory therapy 5. Behavioural groups - e.g., for phobia therapy Psychoanalytic/dynamic group therapy Analytic/dynamic groups include an examination of the conscious and unconscious processes in the group, including resistance, transference, counter-transference. Bion: Described that when a group gets derailed from its task, it goes into one of three basic states: Dependency (group members become dependent on one another and try to elicit protection) Pairing (it is hoped that the formation of a partnership in the group might bring forth a new resolution) Fight-flight (an attack or withdrawal mode) The above 3 features are called basic assumptions. A 4th basic assumption was introduced by Hopper. This is called massification/aggregation where a rigid fusion of identities leads to loss of individuality, or extensive withdrawal leads to loss of mutual dependence. Foulkes: He described the group 'matrix': a web of communications and relationships belonging to a particular group. Foundation matrix: commonalities existing even between total strangers, attributable to characteristics of the human species (e.g., language, race). Foundation matrix is a precondition for the later evolving dynamic or group matrix. © SPMM Course 26 Dynamic matrix: the ever moving and ever developing exchanges that happen between group members on the basis of getting to know one another Factors influencing communication in a group matrix: (Foulkes, 1964) 1. Mirroring 2. Exchange 3. Free floating discussion 4. Resonance 5. Translation The above mostly applies to a psychodynamic group setting. Yalom's curative factors: Yalom cited 11 'curative' factors responsible for the change in groups. The curative factors include the instillation of hope, universality, imparting information (feedback), altruism, corrective recapitulation, socialisation techniques, imitative behaviour, interpersonal learning, group cohesiveness, catharsis and existential factors. Of these, cohesiveness, and learning from feedback are valued positively though other factors may also be important.

Transtheoretical mode? (Prochaska and DiClemente)

A (transtheoretical) synthesis. They identified five common processes of change from analysing psychotherapy models: Consciousness raising Choosing: awareness of healthy alternatives, Catharsis: emotional expression of the problem behaviour Conditional stimuli: stimulus control and counterconditioning, o Stimulus control: Avoidance of stimuli associated with the problem behaviour o Counterconditioning: Training an alternative, healthier response to cue stimuli. Contingency control: Positive reinforcement from others and self-appraisal and improving self-efficacy by self-reinforcement. From these five processes of change, Prochaska and DiClemente identified six stages of change. These are (1) precontemplation, (2) contemplation, (3) Preparation, (4) action, (5) maintenance, and (6) relapse.

Behavioural couples therapy

A specific intervention for alcoholism. It works to increase relationship factors conducive to abstinence. Patient and the spouse are seen together for 15 to 20 outpatient couple sessions over 5-6 months. Daily "sobriety contract", , and the spouse expresses support for the patient's efforts. BCT increases positive feelings and constructive communication. In heterosexual couples in which men are entering treatment, BCT more effective than individual therapy for improving the psychosocial functioning of their children

Maladaptive cognitive distortions (MOSPAD-C)

Aaron Beck is the major proponent of cognitive therapy (CT). The cognitive model proposes that one's view - or cognitions about what happens to them - determines affective and physical changes and other associated psychopathology. Cognitive Dysfunctions: CT identifies three levels of cognitive dysfunctions: negative automatic thoughts, conditional assumptions and basic or core beliefs (or schemas). Negative automatic thoughts or cognitive distortions Conditional assumptions (rules or guidelines for life - they usually start with the phrase 'I must' or 'I should' e.g., 'I should always be pleasant') Core beliefs/schemas (one's appraisal of oneself and they usually begin with - 'I am' e.g., 'I am no good').

Topographical model of the mind

According to this, the mind is divided into three regions: The unconscious - Includes repressed memories, sensations and impulses - Governed by the Pleasure Principle: the instincts seek out gratification - Characterised by Primary Process thinking: defies logic, not restricted by reality The preconscious - At the interface between the Unconscious and the Conscious - Maintains a 'repressive barrier' that censors unacceptable wishes and desires The conscious - Linked in with the reality of the outside world - Characterised by Secondary Process thinking: bound by time and space

Interpersonal Therapy (Klerman & Weissman)

Aims to improve interpersonal functioning Conducted over 12-16 sessions. Involves giving 'sick role' to the patient. It is a time-limited, 'here-and-now' focused therapy. Illnesses viewed as 'medical disorders'. The focuses of treatment are the current interpersonal relationships and their relationship to the development of illness. Inventory of all close relationships is created in early part of therapy. Therapist's stance: In IPT the therapist is an ally and advocate. Non-judgmental, expresses positive regard and congratulates. Tries to have patient find the solution but not afraid to provide advice. Areas of focus: Role Transitions Interpersonal disputes Grief Interpersonal deficits Helpful for clients who have become "stuck" in their ED for reasons associated with problematic relationships. Evidence base: Efficacy that is comparable to imipramine in an NIMH-sponsored trial. IPT is less effective than CBT in depression plus PD. But in general patients without axis 2 disorders respond better to any form of psychotherapy for depression.

Application of CAT?

Applying CAT to Borderline Personality Disorder: Various levels of difficulties are noted in borderline personality disorder. Normally individuals deploy a wide range of flexible reciprocal-role templates as needed during social and interpersonal interactions. Those with borderline personality disorder deploy only a small number of highly maladaptive reciprocal roles. By reciprocal roles, it is meant that when a subject assumes one pole the opponent is pressurized to take up the opposite pole to interact. (Mother - son; teacher-student, etc.). In addition, normal individuals maneuver a smooth transition between roles, for e.g., from being a teacher in the classroom to a colleague in the staffroom. But patient with the borderline disorder show an oversensitive ('hair-trigger') response to stimuli, resulting in unwarranted changes. Capacity for conscious self-reflection and self-control are also impaired in borderline states.

Cognitive Analytic Therapy (Anthony Ryle)

Brings together cognitive and analytic ideas. Can be used in depression, anxiety, personality disorders. Concepts: (PSM) procedural sequence model, role repertoires. Procedural sequence model is an attempt to understand aim-directed action. Sequences may be faulty but repeated without revision. Certain patterns are described below: 'Traps': seen as negative assumptions that produce consequences, which in turn reinforce assumptions. (social anxiety, depressed-thinking and phobic-avoidance traps) 'Dilemmas': a person acts as though available actions or roles are limited or polarised. An example is the placation dilemma: A submissive individual fears expressing anger.-resentment grows- outburst- negative consequences- strengthens fear of expressing anger. 'Snags': appropriate roles or goals are abandoned because others would oppose them, or they are thought to be 'forbidden'. Restricted role repertoire: Undue restriction in the variety of procedural sequences (repertoire), may occur due to impoverished environment, childhood abuse, etc. Leads to neurotic difficulties. Treatment: 16-24 sessions in three phases. Initial phase: an exploration of traps, dilemmas and snags. Middle phase: working through problems, exploring 'target problem procedures.' Ending phase: both patient and therapist write goodbye letters

NICE recommendations for psychotherapy

CBT for psychosis/schizophrenia, depression, anxiety disorders, eating disorders, PTSD Interpersonal Therapy (IPT) for depression, eating disorders MBT for personality disorder MBCT for relapse prevention in depression DBT for personality disorder CAT for depression, anxiety disorders, personality disorders Psychodynamic Psychotherapy for depression, anxiety disorders, PTSD, personality disorder Behavioural psychotherapy for addiction disorders Family/systemic therapy for eating disorders, psychosis/schizophrenia Counselling and supportive psychotherapy: according to patient preference, can be helpful for depression, anxiety disorders, psychosis/schizophrenia, eating disorders, etc., but NOT if another therapy is more strongly indicated

Types of group therapy (2)?

Cognitive Behavioural Groups: Important aspects (described by White & Freeman) comprise: Group Cohesiveness Task Focus Psychoeducational Groups: Mental health experts, or peer counsellors, or members of the community may lead them. Skills Groups: Developing particular skills, eg budgeting. Members can support the development of one another's progress. Therapeutic Communities: The four major principles on which a therapeutic community is based are exemplified by the Henderson hospital model. According to this model, the major components are (mnemonic CPD-R) Communalism (Staff are not separated from inmates by uniforms or behaviours, mutual helping and learning occurs) Permissiveness (tolerating each other and realising unpredictable behaviour can happen) Democratisation (shared decision making and joint running of the unit) Reality confrontation (self-deception or distortions from reality are dealt with honestly and openly by all members).

Defense Mechanisms

Defence mechanisms are normal- they help us manage the interface between unconscious wishes/impulses and external reality (which include prohibitions over the acting out of wishes or impulses). 3 main groups 1. Immature employed in infancy/ childhood. Acting Out: the unconscious is expressed Regression: Denial: Kleinian (or Psychotic) Defence Mechanisms: Also considered immature, the following were described by Melanie Klein Splitting Idealisation and Denigration Projection Projective Identification 2. Neurotic Defence Mechanisms Repression: Intellectualisation: there's a focus on abstract, theoretical concepts and a distancing from the emotions. Rationalisation: a justification is made to explain away some thought or feeling which would rather be kept out of awareness. Reaction Formation: the thoughts expressed are the opposite of what is really being thought Undoing and magical thinking: this is employed in OCD, where a patient may believe that by doing a certain action (e.g., tapping the wall) a tragedy might be prevented. Displacement: thoughts and feelings are directed somewhere less threatening. 3. Mature Defence Mechanisms Humour Altruism Sublimation

Mentalisation-based therapy?

Derived from attachment theory. Mentalizing is the capacity to perceive others' and one's own actions and emotional states as meaningful. Central concepts include: o Maintaining a curious stance o Empathy with pt o Validating the patient's experience. o Goal: increase the patient's mentalizing capacities. The key features of MBT: -Focus on current mental state: i. De-emphasis of hidden unconscious concerns ii. Less focus on the past iii. The aim of therapy is not insight but the recovery of mentalization iv. The therapist avoids describing complex mental states-makes "minor interpretations" b. Therapy creates a 'transitional area of relatedness' c. Enactments during treatment are not interpreted in terms of unconscious but in terms of the situation and emotions immediately before.

DBT (Marsha Linehan)

Developed as a treatment for Borderline Personality Disorder, especially to reduce self-harm. DBT addresses the difficulties faced by a patient with BPD in a hierarchical fashion starting from self-harming behaviours, moving on to therapy interfering behaviours and later behaviours reducing the quality of life. The four modes of treatment: (1) group skills training, (2) individual therapy, (3) phone consultations, and (4) consultation team Key Techniques (mnemonic DICE) Distress tolerance -Crisis survival strategies eg distracting, self-soothing, improving the moment, and acceptance skills such as radical acceptance, turning the mind toward acceptance, and willingness versus willfulness. Interpersonal effectiveness training similar to assertiveness and problem-solving training. Core mindfulness training Emotion regulation skills DBT also involves social skills training such as meditation, assertiveness training, etc. Another approach commonly employed in DBT is validation - recognizing distress and behaviours as legitimate and understandable but ultimately harmful.

Mindfulness-Based Cognitive Therapy (Segal and Teasdale)

Developed for people vulnerable to repeated episodes of depression Background: . MBCT addresses relapse vulnerability. Structure: 8 weeks of mindfulness classes. Psychoeducation Exercises derived from cognitive therapy. Associated with 44% reduction in depressive relapse risk. 2009 NICE Depression Guideline for people who are currently well, but who have experienced three or more past depressive episodes.

Process of dream work

Dream work turns latent into manifest content and includes the following processes: Condensation: two or more unconscious impulses are combined into a single image. E.g., a strict father and a punitive teacher combine in the dream into one frightening monster Diffusion or Irradiation: one unconscious impulse is represented by several images (the opposite of condensation) Displacement: the energy invested in one object or idea gets transferred to another. E.g., a wishful phantasy about murdering one's father becomes represented by shooting a teacher Symbolic representation: an innocent or less highly charged image is used in the place of something that is potentially too overwhelming. E.g.,, a wishful fantasy about shooting one's father becomes an image of hunting a stag

Behavioural analysis

Each behaviour serves a purpose for a person. Identifying such function (may be positive or negative reinforcement) is important to manipulate behaviour through therapy. This forms the principle of functional assessment. Hence, if someone presents with a simple phobia, for example, taking a detailed history to assess the behavioural components must be the first step before prescribing any treatment. In practice, behavioural or functional analysis consists of: 1) Identifying Motivating Operations (why is it happening) 2) Identifying Antecedents/Triggers for the behaviour (what triggers it to happen) 3) Identifying the Behaviour that has been operationalized (what exactly happens) 4) Identifying the Consequences of the behaviour, which reinforces it (what keeps it happening) This is also termed as the antecedents-behaviour-consequence approach of functional assessment. The next step is an active functional analysis, where antecedents and consequences are manipulated in a therapy setting to find their separate effects on the behaviour of interest. Behavioural Treatment plans: Conducting a Functional Analysis can assist in making a behavioural treatment plan. Identify clearly the problems/symptoms, set short-term and long-term goals and objectives, define specific interventions/actions, and decide how outcomes will be measured (e.g., Use of a chart to mark symptom reduction, or to measure change in incidences of aggressive behaviour). Measuring outcomes of behavioural interventions: When measuring a specific behaviour, various dimensions of behaviour can be used as quantifiable measures of the behaviour. These dimensions are: Repeatability refers to the frequency of the behaviour. Temporal extent refers to the duration of each instance of behaviour. Temporal locus refers to the time point at which each instance of behaviour occurs. Response latency is the measured time interval (reaction time) between the onset of a stimulus and the initiation of the response. Inter-response time is the amount of time between two consecutive responses.

Humanistic Psychotherapy

Each of us has the responsibility for finding meaning. The relationship is the treatment. A. Client-Centred Therapy (Carl Rogers) Non-directive. The therapist is warm, genuine and suspends judgement. The patient is believed to have vast resources, the therapist's goal is to facilitate this. The Q-sort technique involves a person sorting cards with statements on them into piles. B. Gestalt Therapy (Perls and Goodman) An existential and humanistic psychotherapy focusing the patient in the present- emphasises personal responsibility. Phenomenological method: aims to increase awareness Dialogical relationship: : 'inclusion': supporting the presence of the client Field-theoretical strategies: this includes a focus on both physical/environmental realities of the client, and those related to the client's mental processes Experiential Freedom: a move towards action

Transactional Analysis?

Examines interactions between people Key ideas: there are 3 main ego-states people consistently use: □ 'Parent' e.g., shouting at a colleague when they have made a mistake. This describes a 'criticising' parental state, but there may also be a 'nurturing' one: taking care of others, as though they were children. □ 'Adult' e.g., making an objective appraisal of reality, behaving in a rational/reasonable way towards others □ 'Child' e.g., getting into a strop if you are criticised for not doing something correctly. This is also the source of emotions, spontaneity and creativity

DYSFUNCTIONS CAUSED BY SAFETY BEHAVIOURS

Generating new symptoms e.g., Hyperventilation, a 'safety behaviour' in response to feelings of choking during panic attacks, produces physiological acid base changes that leads to symptoms such as paraesthesias, dizziness etc. Worsening existing symptoms e.g., active thought suppression, a safety behaviour seen in PTSD and OCD, increases the probability that the intrusion/obsession will occur. Escalating undesirable social responses e.g., those with social phobia who attempt to cough whenever they blush in order to camouflage it may actually attract more response by coughing. Maintaining existing symptoms e.g., rigorous self-monitoring, a safety behaviour in social phobia, can feed to the core symptoms

Development of group therapy?

Group methods were developed in the early 20th century following observations of beneficial group effects in tuberculous patients. JH Pratt was the first major proponent to observe the beneficial effect of the group when he ran general-care instruction classes for recently discharged TB patients. In the 1920s, it was developed by T Burrow, and then furthered after WWII, when a large number of soldiers required psychological treatment. Group Processes: The central premise is that the behaviour and dynamics of the whole (the group) cannot be derived solely from its constituting parts (the individuals within the group). Once formed, the group will develop its own way of existing/it's own culture, with particular norms, roles, relations and goals. Group alliance refers to the quality of the relationship that develops between each individual member and the therapist. Group cohesion refers to the sense that the group is working together towards a common goal. Group coherence is a more evolved group state where the group goes beyond cohesion and becomes self-evolving and able to work through conflicts. Positive identification refers to an unconscious group mechanism in which a person incorporates the characteristics and the qualities of the group. Catharsis refers to the process by which mere expression of ideas and conflicts is accompanied by an emotional response which produces a sense of relief.

Techniques employed in CBT

Guided discovery refers to a style of the interview where sensitive questioning allows patients to reach new interpretations/ reframe their cognitions independently; therapist guides self-discovery and does not prescribe the solution. Questioning identified beliefs: "What evidence do I have for this belief?" "What alternative explanations could there be?" and "What are the advantages and disadvantages of thinking in this way?" Testing Predictions. Predictions about specific symptoms indicating imminent catastrophe can be tested in sessions.

Combining psychotherapies and pharmacotherapies?

Huhn et al. (2014) compared combined therapies vs monotherapies across various disorders. For depression, social phobia, panic disorder and bulimia, combination therapies produced superior effects. Evidence equivocal for schizophrenia and dysthymia where medications were of superior efficacy. Benefits of combined psycho-pharmacotherapies •Improved recovery rates, Faster responses, Decreased relapse, Improved long-term social functioning, Improved meds compliance, Greater reported satisfaction, Lower long-term costs Challenges in offering combined therapies •Higher admin costs, Lack of evidence base, Practical difficulties The authors also highlighted several difficulties in comparing trials: Psychotherapy trials are smaller; with larger effect sizes compared to control. Pharmacotherapy trials more likely to have large samples, blinding, control groups, and ITT analyses. Psychotherapy trials have lower dropouts and better quality follow-up data. Researcher allegiance in psychotherapy trials Psychotherapy meta-analyses often miss reporting conflicts of interest.

Structural model of the mind

Id: full of the instinctual aspects of the individual (e.g., sexual and aggressive impulses), mostly unconscious Ego: the executive organ of the mind- linked in with reality Superego: the seat of internalised morals and values. Can be quite punishing ('thou shalt not...') or helpful in striving for a goal (the Ego Ideal).

Brief psychodynamic therapy

In 1946, Franz Alexander and Thomas French identified the basic characteristics of brief psychodynamic psychotherapy. Time-limited treatment based on psychoanalysis and psychodynamic theory. Somewhat more focused on the here and now Therapists identify and interpret the transference early in the treatment. Therapists formulate a circumscribed focus and set a termination date in advance, and patients work through grief and anger about termination. The methods employed: Goal setting and explicit identification of the anxiety and defenses to be tackled. Focus choosing: Identification of currently active problem. Explore symptom precipitants and associated early trauma and avoidance. Active interpretation: Therapist may guide therapy by use of interpretation at an earlier point than in more prolonged methods. Creating heightened emotional contexts conducive to change Factors predicting good outcomes: Circumscribed problem Strong motivation Able to express feeling at assessment Psychological-mindedness At least one good relationship Evidence of achievement Not actively suicidal, chronically obsessional or phobic Not grossly destructive or self-destructive; not actively abusing illicit drugs

Therapy indications and contra-indications?

Indications for brief psychotherapy: when the problem the patient presents with is fairly well demarcated, when other aspects of the patient's life are functioning reasonably well. Indications for long-term psychotherapy: suitable for more complex difficulties, that affect multiple aspects of a person's functioning and usually involve the person's character or personality Indications for supportive psychotherapy: helpful for periods of transition and adaptation, when a deeper working through particular problems is not required Contraindications for brief or long-term psychodynamic therapies Poor impulse control Poor frustration tolerance Low motivation. Antisocial personality disorder Absence of psychological mindedness (ability to scrutinize and verbalize one's own cognitive processes) Being in the midst of a major life crisis.

Models of family therapy?

Influence of General Systems Theory: - Key Figure: Ludwig von Bertalanffy (biologist) - Key ideas: A system is a set of interconnected components that form a whole; The components show properties of the whole, rather than of individual components; Cycles of feedback between different components within the system continuously create and re-create a basis for interaction. Models of Family Therapy Dynamic To bring to light unconscious factors that influence the way a family functions. Emphasizes individual maturation. Makes interpretations, noticing the formation of alliances, dyads and triads. Family sculpting refers to family members physically arranging themselves in a scene depicting individual view of relationships. Structural Challenges the patterns of behaviours or interactions that disrupt a family structure. Both individual and family sessions used. Family Systems Approach (Bowen) Emphasizes one's ability to retain individual self in the face of familial tension. An emotional triangle is a three-party system where closeness of two members (in either positive or negative sense) tends to exclude a third. The degree of enmeshment is analysed. The therapist maintains minimal emotional contact with family members. Bowen also found a tool to analyse history of families across generations - called the genogram. Strategic (Haley) Aims to find the positives in a system and builds on them. Problems within families can be maintained by over-emphasising them. Positive reframing. Utilizes the domino effect. Psycho-educational The objective is to enhance family support and reduce stress. Focuses on helping families to understand factors that affect stress levels, helps facilitate communication and encourages problem-solving strategies. Behavioural Symptoms are viewed as learned responses that reinforce dysfunctional patterns of relating. Treatment is symptom-focussed and time-limited. The therapist's personality is not important, but action is. The Milan systemic approach (Palazzoli) gives great emphasis on circular and reflexive questioning. In a circular fashion each family member is asked to comment and reflect on each other's response. Paradoxical therapy (Gregory Bateson): Therapist makes the patient intentionally engage in the unwanted behavior. This counterintuitive approach can provide new insights.

Neo-Freudians?

Melanie Klein proposed that aggressive and destructive forces were central components of early development. Paranoid-schizoid Position. In this position the world is split into 'good' and 'bad'. The infant has lots of destructive feelings and thoughts about a 'bad' mother; there is a fear that the 'bad' mother will retaliate and punish the infant (this is the 'paranoid' component). One way for the infant to deal with it is by retreating and cutting off (this is the 'schizoid' component) Depressive position. Once an infant is able to integrate good and bad, and see the mother as having both qualities, then s/he may begin to feel guilty and wish to repair any damage caused. Carl Gustav Jung Founded the school of Analytic Psychology. Jung's psychic apparatus: - Collective Unconscious: mankind' s collective symbolic past, which includes Archetypes (representational images of universal symbolic meaning e.g., the Hero, the Old Wise Man etc.) - Personal Unconscious: an individual's unconscious, comprising Complexes (sets of ideas and feelings triggered by interpersonal interactions) - Ego: individual's conscious mind Other Jungian concepts: - Persona: a mask covering one's personality, but what is shown to the outside world - Anima: the unconscious feminine aspect of a man - Animus: the unconscious masculine aspect of a woman - Shadow: a personification of the less acceptable aspects of oneself - Individuation: the process in which the individual develops self-identity - Extraversion (outgoing) and Introversion (keeping to oneself) Winnicott According to Winnicott, children's psychological development occurs in a zone between reality and fantasy called transitional zone. Play is an important aspect of development of a child. Parental control and impositions can lead to development of a false self different from the real self (theory of multiple self organizations). Transitional Object: an object invested with some special meaning usually given to an important person such as the mother, but which is under the child's control, eg a teddy bear or blanket. Good Enough Mother: a mother who adequately fulfils her caring role but who allows for a gradual disillusionment, thus helping a child develop independence 'Holding' proposed by Winnicott has been modified and adapted for psychotherapy. While administering psychotherapy, the affective and cognitive dispositions of a therapist play important part. This must be differentiated from the cognitive capacity of the therapist to maintain objectivity and focus on selected facts during a discourse - the latter is called 'containing' (Bion). The affective disposition of the therapist, which helps in restraining oneself from retaliating to negative transferences, is called 'holding'. Fairbairn: Proposed libidinal, antilibidinal and ideal parts of an object; also extended as libidinal, antilibidinal and ideal self.

Motivational interviewing? (DARES)

Often used together with TTM and stages of change. In line with Roger's client centred therapy, Miller and Rollnick did work with substance-abusing patients. work collaboratively rather than directly challenge. Resolving the ambivalence towards changing can increase intrinsic motivation - this increase in motivation is the main goal. Change coming from the patient is more powerful. Evaluates the readiness to change before inducing an action. Five general principles: (1) express empathy, (2) develop discrepancy, (3) avoid argumentation, (4) roll with resistance, and (5) support self-efficacy.

Overview of conditioning concepts

Operant Conditioning (Skinner) refers to changing behaviour by the use of reinforcement (may be positive or negative). Aversive conditioning: punishment reduces the frequency of the target behaviour (e.g., the cat is sprayed with water when it scratches the sofa) Reinforcement: a reward increases the frequency of the behaviour (e.g., a dog is given a treat when it fetches the ball) In humans, you can use covert reinforcement: the reinforcer is the imagination of something pleasant. The opposite is covert sensitization when an unpleasant thing is imagined. Shaping (or successive approximation): a desirable behaviour pattern is learned by the successive reinforcement of behaviours that get progressively closer to the desired one. For example: you want a dog to jump through a hoop of fire, so you reward him walking past the hoop, then reward him when he jumps through the hoop, then reward him when he jumps through the hoop when it's on fire. Chaining: reinforcing individual responses occurring in a sequence. For example: in forward chaining a complex sequence such as potty training is broken down into segments and each segment (going to the toilet, pulling one's trousers down, wiping) is rewarded; in backward chaining the segments of behaviour are rewarded from finish to start, for example a child may start with a complete puzzle and then rewards are given for each stage of the puzzle being taken apart. Incubation: an emotional response increases in strength if brief, repeated exposure to the stimulus is present. For example air raid sirens may ring for brief periods at intervals, and in-between the anxiety increases. Rumination can serve to increase anxiety via incubation. Learned helplessness (Seligman): when escape from an aversive stimulus is impossible, trying to escape stops. This was originally a behavioural model for depression. Stimulus control or cue-exposure control: This refers to the control a discriminatory stimulus has on the probability of a behaviour (operant response) because of the reinforcement experienced in the past. In therapy, stimulus control refers to controlling the stimuli that lead on to problem behaviour e.g., avoid walking near a pub to control the cue for drinking. Habituation is a nonassociative learning in which repeated stimulation leads to reduction in response over time as the organism 'learns' the stimulus. Sensitization is an increase in response to a stimulus as a function of repeated presentations of that stimulus. It is the © SPMM Course 16 opposite in result of habituation - yet the conditions that produce them both are, on the surface at least, the same: repetitions of exposure to the eliciting stimulus.

Freud Psychosexual development

Oral (0 to 18 months approx.): The mouth and sucking are the infant's focus. This is no surprise as it promotes feeding and hence the baby's survival. A fixation on this phase in later life may lead to difficulties such as alcoholism or excessive eating. Anal (18 months to 3 years approx.): This is the period around potty training. The infant becomes able to control the function of the anal sphincter, and can therefore decide when to pass stool, and when not to. This sense of power and control is expressed in the term 'anally retentive', indicating that a person's character is controlling. If this fixation persists in adulthood it can manifest in disorders such as OCD (very controlling). Phallic/Oedipal (3-5 years approx.): The genitals become of interest and there is the differentiation between boys and girls. This stimulated the feelings described in the Oedipus Complex, and it is proposed that it's resolution leads to the formation of the Super-Ego, with introjection of parental values (the prohibition of patricide and incest). The Oedipus Complex: Based on Greek mythology, it proposes that in a male infant/young child there is a wish to kill off the father, in order to marry the mother. . In later life a man may choose a wife who has similar qualities to his mother, over whom he also feels possessive. Freud described the opposite dynamic for girls: the Electra complex. He suggested that girls realise they and their mothers don't have a penis; they feel they want one (penis envy); they turn towards the father (and later in life to other men) in order to get a penis and have a baby. This thinking has been quite heavily criticised and Freud admitted not understanding women very well.

Acceptance and Commitment Therapy

Part of third-wave CBT. Draws upon a basic account of language (Relational Frame Theory) Theoretical underpinnings: Cognitive fusion (reinforcement of negative beliefs through vicious cycle) Experiential avoidance e.g anxiety avoidance Strategies -Acceptance: taking a position of non-judgemental awareness -Cognitive Defusion: the opposite of cognitive fusion e.g., I will try to step back and observe my thoughts Mindfulness Self-as-context: the person's identity is caught up in a particular thought Values: patients are encouraged to explore their values Committed action: learning to move in a valued direction. Therapeutic stance: The clinician sidesteps 'literal' language and use metaphors, paradoxes and experiential exercises ; the approach is that of a coach Evidence base: Effectiveness has been demonstrated in helping with depression, work stress, psychosis, substance abuse, chronic pain and borderline PD. It has a similar effect to CBT.

Six stages of change?

Precontemplation: not even considering changing his or her behaviour, does not see the behaviour as a problem contemplation: Person has become aware of problem but is ambivalent about changing; sees equal or more benefits than costs. During preparation, the person has made a decision to change, and is planning a strategy. In action, the person has implemented a plan and is changing the behaviour. In maintenance, the person has been able to sustain the change and avoid reverting for a significant period of time. In RELAPSE the person does revert to problem behaviour - this does not happen to everyone. These stages are not linear in sequence but rather cyclical,

EMDR?

Premise: When a trauma occurs it seems to get locked in the nervous system with the original picture, sounds, thoughts and feelings. This material can combine fact with fantasy and with 'images' that stand for the actual 'emotions'. The eye movements used in © SPMM Course 33 EMDR 'unlock the nervous system' (desensitise) and allow the brain to correctly process the experience (reprocessing). This is based on a highly hypothetical surmise that REM sleep helps in processing the unconscious material and reproducing eye movements that are seen in REM can induce a similar process while awake. This hypothesis has not been proven yet. Originally used with Vietnamese war veterans suffering from Post Traumatic Stress Disorder

Psychodynamic concepts (1).

Psychic determinism: Developmental psychopathology as the source of adult life difficulties. Therapeutic Alliance:. The therapeutic alliance, the transference and the counter transference. Interpretation sheds light on an unconscious process in the patient, making it accessible to the conscious. Transference: The feelings, thoughts and attitudes given to a person in the present, originate from a person or figure in the past; bi-dimensional - it includes replaying past experiences + seeking new relationship with therapist. Transference is unconscious. It is at least partly inappropriate to the present situation. Transference may include idealizing, erotic or highly negative and denigrating feelings and thoughts. Factors increasing transference reactions: 1. Vulnerable personality, especially people with borderline features 2. The patient's appraisal of being in a needy and vulnerable/ dependent position. 3. Frequent contact with the therapist Kohut (1971) defined three types of transferences: mirroring transference, idealizing transference, and twinship transference. 1. Mirroring transference The child feels inadequate and may try to compensate by being perfect or wonderful. In therapy, they are in constant need of a therapist to assure their self-esteem. 2. Idealizing transference Through the idealization of and identification with external objects, the process of preservation of self-esteem is maintained. 3. Twinship transference patient feels comfortable only when the self-object has the same thoughts, values, and appearance. For example, the patient may expect the therapist to feel and act as he or she does. Countertransference: The therapist's spontaneous feelings and emotions that are evoked when s/he 'tunes in' to the patient's unconscious communication, including the patient's transference. Analysing counter-transference can provide insight into a patient's psychic state in the same sense as analysing transference.

Expressive therapies?

Psychodrama (Moreno): the therapeutic dramatization of emotional problems. Soliloquy is a monologue-like recital of thoughts and feelings. Role reversal refers to the exchange of the patient's role for the role of a significant person. The double refers to the auxiliary ego acting as the patient. The multiple double refers to several egos acting as the patient. Mirror technique refers to an auxiliary ego imitating the patient and speaking in the proxy. Art Therapy: May be practiced as 'art as therapy' and 'art in therapy'. Traditionally psychoanalytic (with the interpretation made by the therapist based on unconscious processes), now art therapists employ a number of other approaches, such as cognitive or person-centred. Music Therapy: Similar to art therapy, offering emotional expression through music as facilitated, guided and supported by the therapist. The therapeutic alliance is the most important component. Support Groups: Usually formed of people who have similar problems, or who have had similar experiences. The aim is to facilitate the sharing of thoughts and feelings, provide sympathetic understanding, sometimes give advice.

Psychodynamic concepts (2)

Resistance: Aspects of reality are repeatedly rejected by the patient and they are kept unconscious. Repression resistance refers to patient's difficulty in gaining access to certain ideas and emotions. Transference resistance refers to patient's unconscious wish to keep therapeutic relationship similar to past relationships.. Termination reactions Negative Therapeutic Reaction: In therapy, this is the process by which a step in the right direction (for example making a new realisation) may be followed by a backwards step (such as the return of an old symptom). Freud (1923), who first described this reaction, considered it to be secondary to Thanatos and aggressive impulses. Insight: Being aware of and acknowledging one's mental processes, including ego defence mechanisms. Acting out the unconscious repressed impulse is discharged by means of an action instead of verbalization. Repetition compulsion: The concept of the "repetition compulsion" refers to psychological phenomenon in which a person repeats a traumatic event or its circumstances over and over again. Freud proposed that repetition compulsion occurs during Id vs. Superego conflicts where Id overrides the superego and presents itself. 'Working through': 'Working through' is a process of unlearning prior misconceptions and learning new constructions. Franz Alexander suggested that a further step of corrective emotional experience was necessary in the process of working through Regression in psychotherapy: During psychotherapy, an activation of parts of the patient's personality that is normally hidden may occur. Regression is considered as crucial to successful psychoanalysis. Fear of regression is an important source of resistance to long-term psychotherapy especially in patients with a history of psychosis.

CBT for psychosis?

The CBT approach to psychotic symptoms is based on two different models: 1. Stress-vulnerability model of schizophrenia. Focuses primarily on stressors capable of triggering or exacerbating symptoms. Helps a psychotic individual deal with these stressors and triggers. a. Coping Strategy Enhancement is the primary tool for treatment. These strategies are conventionally divided into affective strategies (e.g., relaxation, sleep, etc.), behavioural strategies (being active, drinking alcohol, etc.), and cognitive strategies (distraction, challenging voices, switching attention away from voices, etc.). b. It is assumed that certain strategies are unhelpful and generate stress in the individual. Relapse indicator identification and control is another strategy used. c. This model primarily aims at relapse prevention and functional recovery. 2. Continuum model: Here the emphasis is on the similarity between normal (but strongly held) beliefs and delusional beliefs. a. This model primarily aims at symptom relief - especially delusions. b. This approach encourages the individual to weigh evidence that contradicts a delusion. Though CBT is gaining popularity in treating psychotic symptoms often, clinicians are unsure about the symptoms targeted in CBT. According to Birchwood, the target is the emotional dysfunction that accompanies psychotic experience and not the psychotic symptoms per se. Turkington described the following elements in CBT for psychosis: Therapeutic alliance - not colluding with delusions but validation. Improving medication adherence. Providing alternate explanations to unusual experiences e.g., normalisation. Decreasing the impact of positive symptoms e.g., addressing the omnipotence of voice. Graded reality testing using peripheral questioning and inference chaining. CBT complements the recovery model for schizophrenia. The interpretation of existing evidence for CBT in psychosis is highly controversial; while bodies such as NICE and British Psychological Society have embraced CBT in their framework of treating psychosis, many experts question the validity of the appraised evidence. It is still unclear when and how CBT should be delivered, what are the most effective and essential components of such CBT, reliability of CBT among various therapists, what kind of patient is the most suited. (

Maintaining factors/cognitions?

The presence of cognitive distortions alone is often insufficient to explain the maintenance of several symptoms. Anxiety is maintained by 1. Situational avoidance/escape behaviour, which strongly reinforces the anxiety response. 2. In-situation safety behaviours: Variety of subtle behaviours/internal mental processes that most patients engage in while in a fearful situation. 3. Attentional deployment: Patients with panic or hypochondriasis fear certain bodily sensations, and selectively pay more attention, becoming aware of sensations that others do not even notice. 4. Rumination: Rumination is not a problem-solving tool in most of those with depressive/anxious cognitive style - instead it serves to elaborate or make threats more abstract and hence difficult to cope with.

Supportive psychotherapy

The primary aim is to support reality testing, provide ego support and attempt to reestablish usual level of functioning. Usually employed in otherwise healthy patients with overwhelming ongoing crises and those with ego deficits. Also useful in those who are not psychologically motivated to 'explore' themselves. This is not time limited and the therapist must be predictable available in times of need. Problem solving, advice, reinforcement and reassurance are the main tools.

Predictors of response to psychoterapy

YAVIS "young, attractive, verbal, intelligent, and successful." There is no proof that this is true. This idea first appeared in 1964 in the book Psychotherapy: The Purchase of Friendship by the US psychologist William Schofield. Best predictor of outcome in any psychotherapy is the degree of the therapeutic alliance. Significant effect on clinical outcome for various psychotherapies and also for active and placebo pharmacotherapy. Ratings of patient contribution to the alliance are significantly related to treatment outcome while the ratings of therapist contribution to the alliance and outcome are not significantly linked. In contrast to the therapeutic alliance, positive perception of therapist throughout treatment (idealization) is not necessary and may even be counterproductive in some cases.