Transcript Basic Psychological Treatments - Yorkshire and the Humber Deanery

Basic Psychological Treatments
Dr Tuoyo Awani
ST6
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
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?
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
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
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
Behavioural / Cognitive behavioural
therapy (Beck)
• Practicalities:
– Usually 10-20 sessions
– Weekly, approx 1 hour
• Structure:
– Structured
– Collaborative, therapist guides discovery,
teaches skills
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
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
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 patient’s 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
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
Procedural loop in CAT
Courtesy Wikipedia 2014
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,
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
Motivational interviewing
(Miller, Rollnick)
• Practicalities: 1:1
• 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
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
Family Therapy 2
• STRUCTURAL (MINUCHIN)
• Looks at family rules, coalitions, boundaries and power hierarchies
• “Normative” family structure: hierarchy between generations, semipermeable 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
Group Therapy
Pratt, 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
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
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.
THERAPEUTIC COMMUNITIES (MaxwellJones, 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
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
Bipolar affective disorder
NICE 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
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
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
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)
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
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
Doesn’t 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
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
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
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
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
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
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
EMI 3
Types of family therapy
A: Cognitive
B: Dialectical
C: Dynamic
D: Strategic
E: Solution focused
F: Structural
G: Eclectic
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.
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
EMI 5
• Psychological treatment in group settings:
A. Cohesiveness
F. Dependence
B. Vicarious learning
G. Fight-flight
C. Counter-dependence
H. Pairing
D. Free floating discussion
I. Universality
E. Interpreting transference J. Conditioning
From the options above, Choose
1. Two curative factors in group therapy.
2. Three factors that hinder working in groups.
3. Two factors that are found in psychodynamic
groups.
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
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
halfway SAPE for a long
case
End
CT3
2 cases completed
2 sets of SAPEs
Psychotherapy ACE
Thanks For Listening