Basic Psychological Treatments

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Basic Psychological Treatments

• Dr Tuoyo Awani
• ST6

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Outline

• Gain a basic understanding of different main
  psychotherapies
• Only cover psychodynamic therapy and CBT very
  briefly, as other lectures on these
• Know the indications for different therapies
• Know the key techniques and concepts
• Know the important names
• Practice psychotherapy related exam questions

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Characteristics of different psychotherapies

• Practicalities How many sessions? How often?
• Structure How structured? Is there homework?
• Key ideas What does therapy focus on? What is
  the theory behind it?
• Interventions What are the main treatment
  methods?
• Indications What problems or diagnoses is it
  suitable for?

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Psychodynamic Psychotherapy(Freud, Jung, Klein,
Winnicott)

• Practicalities
• Brief / focal therapy (Balint, Malan) 4-6
  months, 1-2 times/week
• Long-term exploratory therapy 1 year or more
• Structure
• Relatively unstructured, without homework
• Key ideas
• Understand aspects of problem previously unaware
  of (unconscious conflict)
• Aims is more broad than removing single symptoms
  or problem behaviours

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Psychodynamic Psychotherapy 2

• Interventions
• Discuss past and recent problems, therapists
  suggests links between these (interpretations)
• Therapeutic relationship central and discussed
• patient transfers feelings and attitudes from
  past relationships onto the therapeutic one
  (transference)
• therapist notes their feelings and attitudes
  towards the patient (countertransference)
• Therapist is able to tolerate difficult emotions

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Psychodynamic Psychotherapy 3

• Indications
• Evidence base relatively poor
• Difficulties in relationships, low self esteem
• Patients who have some insight and motivation
• Patients who understand the problem in
  psychological terms (at least partly)
• Patients able to cope with feelings evoked in
  therapy (ego strength)
• Patients with some capacity to form and maintain
  relationships

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Behavioural / Cognitive behavioural therapy (Beck)

• Practicalities
• Usually 10-20 sessions
• Weekly, approx 1 hour
• Structure
• Structured
• Collaborative, therapist guides discovery,
  teaches skills

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Behavioural / Cognitive behavioural therapy 2

• Key ideas
• Focuses on current problems
• Behaviour therapy reactions can be linked to
  stimuli eg. phobias (classical conditioning,
  Pavlov),
• Reinforcement/punishment of behaviours affects
  their frequency (operant conditioning, Skinner)
• Cognitive therapy Thoughts, emotions, physical
  symptoms and behaviours are linked, altering one
  will have a knock on effect on the others
• Past experiences lead to core beliefs and
  dysfuctional assumptions, which influence our
  thoughts and behaviour in the present

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Behavioural / Cognitive behavioural therapy 3

• Interventions
• Behavioural interventions eg. Graded exposure,
  ERP, activity scheduling, behavioural experiments
• Cognitive interventions eg. Evidence for and
  against thoughts, thinking biases, working on
  core beliefs and assumptions
• Indications
• Depression, anxiety, PTSD, eating disorders,
  schizophrenia

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Dialectical behavioural therapy (DBT)(Linehan)

• Practicalities / Structure Approx 1year
• Group skills training approx 2.5 hours/week
• Individual psychotherapy
• Key ideas
• Patients need new ways of solving problems
• Validate patients thoughts, feelings and actions
  
• Interventions
• Core mindfulness skills
• Interpersonal effectiveness skills
• Emotion regulation skills
• Distress tolerance skills
• Look at applying skills and motivational issues
  in individual therapy
• Indications
• Borderline personality disorder

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Cognitive analytic therapy (Ryle)

• Practicalities Usually16 or 24 sessions
• Structure Some structure, reformulation diagram
  central
• Key ideas
• Identifies reciprocal roles
• Identifies procedural loops
• Patient actively involved in the process
• Interventions
• Reformulation letter
• Techniques from dynamic and cognitive behavioural
  therapy
• Indications
• Small evidence base
• Borderline personality disorder, eating disorders

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Procedural loop in CAT
Courtesy Wikipedia 2014
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Interpersonal Therapy (IPT)(Klerman Weissman)

• Practicalities 12-20 sessions
• Structure
• 1st phase information gathering,
  psychoeducation, interpersonal inventory and
  chart, select a focus
• 2nd phase Active work on role transition, role
  conflict, grief or interpersonal deficits
• 3rd phase Relapse prevention, grief over ending,
  transition to independence
• Key ideas Interpersonal problems are central to
  many psychiatric problems
• Interventions
• Link symptom change to interpersonal events
• Experiment with new interpersonal strategies
• Indications depression,

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Eye movement desensitization and reprocessing
(Shapiro)

• Practicalities Usually about 3-12 sessions
• Structure Set phases to work through
• Key ideas Eye movement enhances the processing
  of traumatic memories by
• increases interaction of 2 brain hemispheres
• or/ activates a state similar to REM sleep
• or/ keeps some focus on current reality
• or/ not an active component
• Interventions
• Self-soothing techniques in preparatory phase eg.
  safe place image or memory
• Bilateral stimulation eg. moving eyes back and
  forth inducing saccadic eye movement
• Attending to a disturbing memory briefly (15-30
  secs)
• Linking a positive thought to the image
• Indications PTSD

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Motivational interviewing (Miller, Rollnick)

• Practicalities 11
• Key ideas Client-centred but semi-directive
• Confrontation and persuasion increase resistance
• Reluctance seen as natural and not a client trait
• Increases self-efficacy and explore ambivalence
• Interventions
• Empathy, rolls with resistance, affirmation
• Reflective listening with focus on change talk
• Explores discrepancy between now future goals
• Indications
• Eliciting behavioural change
• Especially drug and alcohol problems
• Stages of change precontemplation or
  contemplation stages

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Family therapy

• Practicalities (Extended or nuclear) family
  group
• May use a 2 way mirror, with a reflecting team
• Key ideas Problems are generated by malfunction
  of the family system, not one individual
• Focuses on patterns of relationships , not causes
  or diagnoses
• Focuses on what goes on between persons rather
  within a person
• SYSTEMIC (MILAN SCHOOL)
• Symptoms have a function stabilise the system
• Circular and reflexive questioning
• Focuses on belief systems
• Difficulties not with individual, but with family
  system
• STRATEGIC (HALEY)
• Patterns of interactions between family members
• Solutions often perpetuate problems
• Relabel symptoms as helpful
• Prescribe symptoms

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Family Therapy 2

• STRUCTURAL (MINUCHIN)
• Looks at family rules, coalitions, boundaries and
  power hierarchies
• Normative family structure hierarchy between
  generations, semi-permeable boundaries
• Position family members or make some observers to
  disrupt dysfunctional relationships
• Challenges rigid or absent boundaries
• OTHER MODALITIES problem solving approaches,
  dynamic methods, cognitive behavioural, trans
  generational therapy
• Indications Child and adolescent mental health
  problems, eating disorders, schizophrenia,
  marital problems

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Group TherapyPratt, Burrow Schilder

• MANY MODALITIES
• Psychoeducation groups
• CBT based groups
• 12 step groups eg. Alcoholics anonymous
• Self-help groups
• Non verbal expressive groups (art, music etc)
• Psychodrama (Moreno)
• PSYCHODYNAMIC GROUPS
• Group used to develop and explore interpersonal
  relationships
• Bion Basic assumptions in groups
• Dependence on therapist to solve problems
• Pairing hoping for a pairing to solve group
  problems
• Fight-flight retreating or battling with others

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Therapeutic factors in Groups (Yalom)

• Instillation of hope inspiration from others
  recovering
• Universality shared experiences
• Imparting of information
• Interpersonal learning feedback from others
  increases self-awareness
• Altruism helping others increases self-esteem
• Corrective recapitulation of the family group
  transference from family experience to therapy
  group
• Development of socialising techniques
•  

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THERAPEUTIC FACTORS IN GROUPS (YALOM) cont

• Imitative behaviour learning through modelling
  eg. sharing emotions, showing concern
• Group cohesiveness acceptance and validation
  (suggested as the primary therapeutic factor in
  group therapy)
• Catharsis relief through expression of emotion.
• Existential factors Learning the need to take
  responsibility for one's own life and decisions
• Self-understanding causes of own problems and
  motivations behind own behavior.

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THERAPEUTIC COMMUNITIES (Maxwell-Jones, Foulkes)

• Usually residential (therapist and patients)
• Increasingly now supported heavily with day units
• Group psychotherapy and practical activities
• Moderate to severe personality disorder, complex
  emotional and interpersonal problems
• Emerging funding constraints threatening the core
  implementation of TC, and forcing some to close
• 4 PRINCIPLES IN TC TREATMENT (RAPAPORT)
• Permissiveness tolerance of behaviour
• Reality-confrontation feedback from others
• Democracy shared decision-making
• Communalism close, shared living

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Depression 1

• Therapy efficacy 50-60, group individual
  similar
• Relapse 50 over 1 year, less with booster
  sessions
• Approximately equivalent to medication,
• Medication may be more effective in the severely
  depressed
• NICE SUGGESTS
• Mild guided self help, computerised/brief CBT,
  counselling
• Moderate / severe antidepressant priority
• Consider therapy if refuse antidepressant or poor
  response
• Consider medication and CBT together in severe
  depression
• CBT 1st choice of psychological intervention,
  16-20 sessions
• IPT if preferred by patient or clinically
  indicated
• Couple focused therapy if individual ineffective
• Mindfulness based CBT in recurrent depression

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Bipolar affective disorderNICE suggests

• Moderate depression, not responding to
  medication
• Structured psychological therapy
• Focus on depressive symptoms, problem solving,
  social functioning, medication concordance
• Ongoing mild-moderate affective symptoms
• Structured psychological therapy, 16 sessions
  over 6-9 months
• Focus on routine, concordance, psychoeducation,
  monitoring mood, early warning symptoms, coping
  strategies
• Family focused intervention, over 6-9 months
• Focus on psychoeducation, improving
  communication, problem solving

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Anxiety disorders 1

• CBT recommended for all
• Panic disorder/agoraphobia (7-14 sessions)
• Agoraphobia needs exposure
• Generalised anxiety disorder (16-20 sessions)
• Cognitive methods and applied relaxation have
  evidence
• Obsessive compulsive disorder ERP
• Stepped approach based on functional impairment
• Less effective without compulsions, hoarding
• Social anxiety disorder
• Thoughts, safety behaviours, attentional
  processing
• Group and individual therapy similar efficacy

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Post-traumatic stress disorder (PTSD),NICE
suggests

• Psychological debriefing may be harmful
• Trauma focused CBT
• EMDR (Eye movement desensitisation and
  reprocessing) 3 months or more after event
• Needs to include exposure
• Usually 8-12 sessions
• 90 minute sessions when trauma discussed

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Anorexia nervosa, NICE suggests
Adults Focal dynamic psychotherapy, CAT,
CBT, IPT Family interventions focused on eating
problems, 6 months or more of therapy
Children / adolescents Family interventions
focused on eating problems Individual
appointments for the young person
BULIMIA NERVOSA, NICE SUGGESTS

• CBT, 16-20 sessions
• If ineffective or declined IPT (takes longer to
  achieve results)

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Borderline personality disorder

• Evidence for dialectical behaviour therapy (DBT)
• focuses on behaviours esp. impulsivity and
  suicidality
• Evidence for structured psychodynamic approach,
  including group treatment
• may have more impact on mood and interpersonal
  functioning
• CAT, Schema-focused CBT need more research
• NICE suggests
• explicit, integrated theoretical approach
• Same approach team and therapist
• Up to 2x/week, not usually less than 3 months

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Schizophrenia, NICE SUGGESTS

• CBT (16 sessions) for all patients, NICE
  suggests
• Evidence for CBT
• In acute episodes may shorten episodes reduce
  symptoms
• In chronic patients improves mental state
• Doesnt alter relapse or readmission rates
• Possible adverse impacts in vulnerable
  individuals
• Family interventions (10 sessions) when close
  contact with family, NICE suggests
• Include problem solving or crisis management work
• Evidence suggests CBT based sessions
• Art therapies recommended for consideration by
  NICE
• Especially if negative symptoms

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MCQ 1

• An otherwise fit and intelligent 23 year old man
  has features of a moderate depressive illness.
  The correct initial treatment according to NICE
  is A. CBT B. SSRI C. CBT SSRI D. TCA

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MCQ 3

• Which of the following is true regarding CBT
• A CBT has been shown to be as effective as
  treatment with antidepressants in depression of
  moderate severity.
• B CBT is the preferred treatment for borderline
  personality disorder
• C CBT is the only psychological intervention
  recommended by NICE for anorexia nervosa
• D Antidepressants should be used before CBT in
  the treatment of PTSD
• E CBT is not effective in social phobia

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MCQ 4

• Which of the following is correct
• A Psychodynamic therapy is effective in
  schizophrenia
• B Individual therapy is usually more effective
  than group therapy
• C Cognitive therapy is effective for
  agoraphobia
• D There is evidence for cognitive analytic
  therapy in anorexia nervosa
• E Unstructured psychotherapy is recommended in
  bipolar affective disorder

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MCQ 5

• Which of the following is true regarding CBT
• A Incorrect theory of mind is part of the CBT
  model
• B Underlying assumptions are process that
  belong to the dynamic unconsciousness
• C CBT is non-directive
• D In exposure and response prevention
  obsessions are resisted
• E Behavioural experiments are used to test out
  negative cognitions

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EMQ 1

• A Mindfulness CBT
• B Exposure and response prevention
• C Graded Exposure
• D Schema focused CBT
• E Activity scheduling
• F Functional analysis
• G Trauma focused CBT
• Identify the most appropriate technique /
  approach from those listed for each of the
  scenarios below
• 1 A 25 year old woman with a diagnosis of
  borderline personality disorder
• 2 A 42 year old man with severe depression who
  lacks motivation and has poor concentration
• 3 A 33 year old man with a recurrent depressive
  illness who has experienced a relapse despite
  antidepressant medication and tends to ruminate
  about his problems
• 4 An 8 year old girl with a phobia of vomiting
  who is avoiding many things which she associates
  with a risk of vomiting

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EMQ 2

• A Ryle
• B Beck
• C Linehan
• D Klein
• E Wolpe
• Which of the people above is associated with each
  of the therapies or interventions listed
• 1 Psychodynamic psychotherapy
• 2 Cognitive analytic therapy
• 3 Dialectical behavioural therapy
• 4 Cognitive behavioural therapy

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EMI 3

• Types of family therapy
• A Cognitive E Solution focused
• B Dialectical F Structural
• C Dynamic G Eclectic
• D Strategic H Systemic
• Select which type of therapy is described in each
  scenario below
• 1. The therapist is identifying, ascertaining and
  developing a firm family hierarchy
• 2. An emotionally intertwined family of an
  adolescent with anorexia nervosa need the forces
  and beliefs which influence their behaviour
  towards each other to be revealed
• 3. A family are helped with a novel practical
  strategy to break the negative cycles of
  behaviour identified in therapy. The therapist
  views the problems as dysfunctional communication.

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EMQ 4

• A Thinking biases
• B Transference
• C Reciprocal roles
• D Mindfulness
• E Dysfunctional assumptions
• F Circular questioning
• G Interpersonal role disputes
• Which of the above features or concepts is
  associated with the therapy below
• 1 Cognitive analytic therapy
• 2 Dialectical behavioural therapy
• 3 Psychodynamic psychotherapy

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EMI 5

• Psychological treatment in group settingsA.
  Cohesiveness F. Dependence B. Vicarious
  learning G. Fight-flightC. Counter-dependence
  H. Pairing D. Free floating discussion I.
  UniversalityE. Interpreting transference J.
  ConditioningFrom the options above, Choose1.
  Two curative factors in group therapy.
• 2. Three factors that hinder working in groups.
• 3. Two factors that are found in psychodynamic
  groups.

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EMQ 6

• A Eye movement desensitisation and reprocessing
• B Brief psychodynamic psychotherapy
• C Interpersonal therapy
• D Cognitive behavioural therapy with exposure
  and response prevention
• E Family interventions
• Which of therapies above is recommended by NICE
  for the disorder below
• 1 Depression
• 2 Schizophrenia
• 3 Post-traumatic stress disorder
• 4 Obsessive compulsive disorder

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ST1-3 Psychotherapy requirements

• CBD group 30 sessions
• Psychotherapy cases 2 of different modalities
  and durations

Year Psychotherapy Experience WPBA
End CT1 Attended first 6 months of a case based discussion group 1st (6 month) CBD
End CT2 Finish 12 months of case discussion group Short case completed or Half-way through a long case 2 CBD sheets (6 12 months) 1 set of SAPEs for short case or half-way SAPE for a long case
End CT3 2 cases completed 2 sets of SAPEs Psychotherapy ACE
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• Thanks For Listening