1. Psychological therapies Dr Chris Williams

2. Today’s objectives. You will:
Gain an overview of the range of psychological therapies
Look at the four main models of psychological treatments used in the NHS.
Think about how a patient could be thought about in each of the models.
This is the first of two sessions concerning clinical assessment. There are very clear objectives in the session, and make the link that this is similar to CBT approach and there again there are very clear objectives for each treatment session. Read through the objectives that are raised on the Slide.

3. Task - at end Split into pairs.
How would you approach working with this depressed man in these four different types of therapy?
What would be different?
What would be similar?

4. Psychotherapy: Group discussion
What goes through your mind when you think about the term “psychotherapy”?
Would you want it yourself? Would you tell others you were having/had received it?
How would this compare with say an antibiotic?

5. Psychotherapy
Is a blanket term for those treatments which offer psychological rather than physical or social interventions.
Those usually available on the NHS include CBT, Psychodynamic, Counselling, Family Therapy.

6. Key document www.dh.give.uk and search for title
– depression, anxiety, PTSD, self-harm, Eating disorders
SIGN has some materials

7. The CBT model
Aims to reduce symptoms by changing specific behaviours and thoughts which maintain specific symptoms.
Name associated with it is Professor Aaron Beck.
Unhelpful/extreme thoughts (The C bit of CBT) and reduced activity/unhelpful behaviours (the B bit of CBT) are the main targets for change in CBT as they may be contributing/maintaining the clinical problem
This Slide summarises the basic CBT model that there characteristic changes in thinking and behaviour as part of psychiatric disorders. Normal ways of thinking and acting alter/are shifted/become biased and are part of the problem. These are extremely unhelpful thinking, and produce activity in unhelpful behaviours. These are the targets for change within CBT.

8. CBT: a simple message What you think affects how you feel
Thinking Feelings
What you think affects what you do
In essence, summarise how much of the academic research although important, has basically found that:
a)   what people think of exactly how they feel
b). what people think of it as what they do.
These links are called Thought-feeling links, and Thought-behaviour links. These relationships are what are looked for in CBT assessment.
Ask them to note the double-headed arrows and say we will come back to that later
Thinking Behaviour

9. The CBT model In anxiety and depression:
Thinking changes characteristically:
extreme and unhelpful
e.g. worthlessness, guilt, incompetence, failure, hopelessness
Behaviour changes characteristically:
reduced activity
avoidance
- unhelpful behaviours
Unhelpful/extreme thoughts (The C bit of CBT) and reduced activity/unhelpful behaviours (the B bit of CBT) are the main targets for change in CBT as they may be contributing/maintaining the clinical problem
This Slide summarises the basic CBT model that there characteristic changes in thinking and behaviour as part of psychiatric disorders. Normal ways of thinking and acting alter/are shifted/become biased and are part of the problem. These are extremely unhelpful thinking, and produce activity in unhelpful behaviours. These are the targets for change within CBT.

10. CBT treatment 1). Alter unhelpful/extreme thinking
Not the same as positive thinking
Identify/test out extreme thoughts
Balanced conclusion based on all the evidence
2). Alter unhelpful behaviours
The purpose of Assessment is to lead on to treatment

11. Experiment: (in pairs – 5 minutes)
Q. If you talk to someone who is depressed/fed up, what do do they:
Feel emotionally
Feel physically
Say
Do/not do
What life situations do they often face?
Use the language they would use
Feedback time
Group Task Involvement
For the feedback component (after 5 mins working in pairs), one trainer stands with the flip chart and the other seeks group comments. The task is to ask the group to shout out the sorts of symptoms they see when a patient walks in who is experiencing depression. What do such patients do or say?
The other trainer stands at the flip chart and imposes a structure on what is said to represent a five areas assessment model. i.e. the answers are clustered into:
a)   situations relationship and practical problems
b)   altered thinking
c)   altered feelings
d)   altered physical symptoms
e)   altered behaviour
These should be clustered on the flip chart in the five areas format which is also shown on the next slide. Do not put the next slide up until each of these clustered areas has been summarised. When it has, move on.

12. The Five Areas Assessment Model
Life Situation, relationship and Practical Problems
Altered Thinking
Altered Feelings
Altered Physical Symptoms
Summarises the five areas assessment - overall summary of patient's current problems.
Talk through each box in sequence and link back to the flip chart to show that the five areas approach can provide a detailed summary of the different problem areas for a patient. Make the link that this is useful in assessment from understanding the patient's problems, but this is not just a theoretical issue but that it also will inform intervention and that each of these areas can lead to improvement.
Q. How well does this fit with your own experiences with patients?
Is it helpful/unhelpful
Any problems with it?/doesn’t fit – if so, this is great!
Note the Thought-Feeling and Thought-Behaviour links, but also the links between each of the areas. Note also the double-headed arrows
Altered Behaviour

13. A Five Areas Case Summary -1
Life Situation, relationship and Practical Problems
£2500 debt, arguments with husband
Thinking
I’m useless, Everything’s wrong
Feelings
Low, anxious, angry
Physical
Sleep + appetite red. Weight loss
One way that a Five Areas approach can be used is to focus the clinical assessment and summarise the range or problem areas faced by the person, as illustrated on the slide. Talk through the problem areas, and emphasise the links between each area.
Make a comment that interventions can be in any of the areas, and that intervening in any of the areas is likely to lead to benefits in the other areas too. Traditionally treatments have often been with antidepressants (point to the physical box).
Q. Ask if the person benefits, what other areas are affected?
The answer is all of them – they may be less depressed, enjoy things again (altered feelings), have less negative thinking (altered thinking), have more energy and sleep better (altered physical symptoms), do more activities (altered behaviour), and be more able to relate to others and tackle practical problems with confidence (situation, relationship and practical problems).
Behaviour
Argue with husband, stay in

14. Unhelpful thinking styles - 1
Typical thoughts
Bias against myself
Overlook my strengths
Focus on my weaknesses
Downplay my achievements
My own worst critic
Putting a negative slant on things
(negative mental filter)
See things through dark tinted glasses
Put a negative slant on things
Having a negative view of the future
Jump to the very worst conclusions
Catastrophising
Make negative predictions about the future
Predict that things will go wrong

15. Unhelpful thinking styles - 2
Typical thoughts
Mind-reading
Negative view of how others see me
Mind-read what others think of me
Assume that others don’t like me/judge me badly
Bearing all responsibility
Take things to heart
Take the blame ++
Feel overly responsible
Make extreme statements/rules
Use the words “must”, “should”, “ought” and “always”/”never” a lot.
High standards ++

16. Task: (in pairs) Q. What is your first thought?
Scenario:
You travel to meet your friend at 10am, but they don’t turn up.
You are giving a talk and you notice someone in the audience yawning.
You go to do some last minute photocopying - and the machine jams halfway through. It needs the engineer.

17. Key Point: These thinking styles are normal/everyday occurrences
In anxiety and depression they are:
Experienced more frequently - unhelpful thoughts “pop” into mind ++
Harder to challenge and believed more
Helpful/balanced thoughts are crowded out

18. The impact of extreme thoughts
What is unhelpful about extreme thoughts
1. “There’s nothing I can do”
2. “She hates me”
3. “I won’t enjoy it”
Q: If I believed these thoughts, how would I feel?
Q: If I believed these thoughts, what would I do differently

19. How does CBT work?
Identifies – and then challenges extreme and unhelpful thoughts
Gathers evidence for and against the thought
Come up with a balanced conclusion
Overcome reduced activity, avoidance and unhelpful behaviours.
More next session

20. Psychodynamic psychotherapy
Exploratory approach to help the patient develop insight into why they are distressed/ causing distress or suffering from symptoms.
Prominence given to the unconscious.
Freud is the father of this approach
Later developments by Jung, Adler, Klein, Anna Freud, Winnicott - different schools.

21. Psychodynamic psychotherapy
Much more of an emphasis on the past, particularly on childhood events
It emphasises the importance of mental representations of early life experiences in the present & the impact they have on current relationships.

22. Psychodynamic psychotherapy
Exploratory and less directive.
Must make links between past and present.
Increase patient’s understanding that their current patterns of relating to others have their origins in past (childhood).
Tends to last for longer time (can be years) although recent shorter therapy advocated.

23. Psychodynamic psychotherapy
Freud was a major figure in 20th Century thought.
Neurologist.
Outlined three theories to account for mental processes.
Topographical, structural, developmental.

24. Psychodynamic psychotherapy
Topographical theory & unconscious mind.
Conscious and unconscious mind
Unconscious thoughts and feelings which influence behaviour.
Thought may be unconscious because it is consciously suppressed or unconsciously repressed.

25. Psychodynamic psychotherapy
Structural Theory.
Mind can be conceptualised as having three parts - the Superego, ego & id.
Superego - what is thought of as conscience.
Ego - rational part of your mind.
Id - contains the instincts of sexuality & aggression

26. Psychodynamic psychotherapy
Developmental Model - series of stages.
Oral - first year.
Anal - 2nd, 3rd years.
Genital - 3-5th year
Theorised that problems occurred at these times cause characteristic mental symptoms later on e.g. OCD and anal phase.

27. Psychodynamic psychotherapy
Conflict - may also be conscious or unconscious.
E.g. Mrs B wants to have Mother to live with her - but postpones moves due to worsening back pain.
Unconscious conflict may lead to the development of symptoms

28. Psychodynamic Psychotherapy
Defence mechanisms - protects us from emotional distress by preventing the unconscious becoming conscious.
Can be on a spectrum from conscious to unconscious.
Everyone uses them - not necessarily pathological indeed we need them!

29. Psychodynamic Psychotherapy
Defence mechanisms - major one is repression.
E.g. choosing not to remember you have an exam next week.
Reaction formation, denial, rationalisation, projection.

30. Psychodynamic Psychotherapy: what does it look like?
Can be individual or group.
Uses therapeutic relationship as with all other models of psychotherapy.
But…uses the relationship to explore the defences, conflicts, and the unconscious.
Central to this is how the current relationship reflects past relationships in the patient’s life – can also include interpretation of dreams
Lie/sit down e.g. on a couch or bed– long silences

31. Psychodynamic Psychotherapy
Working alliance
Transference: how the patient reacts to you
Counter-transference: how we react to the patient

32. Counselling
Aims to offer a supportive, non-directive relationship in which the patient can work out solutions to personal difficulties.
Not intended to make the patient confront their anxieties.
Really to strengthen existing coping strategies.
Mild to moderate psychological problems
Life crises & problem solving (HIV, Cancer, bereavement in NHS).

33. Counselling Most common approach.
Common in general practice in the UK.
Anyone can call themselves a ‘counsellor’.
Common in voluntary sector.
Focuses on warmth, empathy and genuineness
Avoids providing “answers”

34. Family therapy
Aims to see if and how the problem of the identified patient is maintained by the needs of the family.
A number of schools (Systemic).

35. Family therapy
Usually in NHS used for childhood problems where one or more children in the family are showing emotional or behavioural difficulties..
Uses concept of the ‘System’: the system is set up to be self-maintaining and resists change (good or bad)
System says that lots of interactions within the family all causing the ‘picture’ in the individual.

36. Case example Cameron is 32 and is depressed.
Already on medication from GP.
Lives with his mother; he doesn’t work.
Witnessed alcoholic father/ domestic abuse
Now has panic attacks on leaving house
Took an overdose of paracetamol.
Upset that his sister is leaving for New Zealand.

37. Task – 5-10 mins Split into pairs.
How would you approach working with this depressed man in these four different types of therapy?
What would be different?
What would be similar?

38. Feedback
Any thoughts?
How would you approach working with this depressed man in these four different types of therapy?
What would be different?
What would be similar?
Q. How easy is it to access psychotherapy in the UK?

39. Any questions

40. The End Next week: Self-help and Psychotherapy
Problem solving approaches
CBT- focus on reduced activity and identifying extreme and unhelpful thoughts