2Today’s objectives. You will: Gain an overview of the range of psychological therapiesLook 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.
3Task - 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?
4Psychotherapy: 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?
5PsychotherapyIs 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.
6Key document www.dh.give.uk and search for title – depression, anxiety, PTSD, self-harm, Eating disordersSIGN has some materials
7The CBT modelAims 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 problemThis 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.
8CBT: a simple message What you think affects how you feel Thinking FeelingsWhat you think affects what you doIn essence, summarise how much of the academic research although important, has basically found that:a) what people think of exactly how they feelb). 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 laterThinking Behaviour
9The CBT model In anxiety and depression: Thinking changes characteristically:extreme and unhelpfule.g. worthlessness, guilt, incompetence, failure, hopelessnessBehaviour changes characteristically:reduced activityavoidance- unhelpful behavioursUnhelpful/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 problemThis 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.
10CBT treatment 1). Alter unhelpful/extreme thinking Not the same as positive thinkingIdentify/test out extreme thoughtsBalanced conclusion based on all the evidence2). Alter unhelpful behavioursThe purpose of Assessment is to lead on to treatment
11Experiment: (in pairs – 5 minutes) Q. If you talk to someone who is depressed/fed up, what do do they:Feel emotionallyFeel physicallySayDo/not doWhat life situations do they often face?Use the language they would useFeedback timeGroup Task InvolvementFor 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 problemsb) altered thinkingc) altered feelingsd) altered physical symptomse) altered behaviourThese 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.
12The Five Areas Assessment Model Life Situation, relationship and Practical ProblemsAltered ThinkingAltered FeelingsAltered Physical SymptomsSummarises 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/unhelpfulAny 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 arrowsAltered Behaviour
13A Five Areas Case Summary -1 Life Situation, relationship and Practical Problems£2500 debt, arguments with husbandThinkingI’m useless, Everything’s wrongFeelingsLow, anxious, angryPhysicalSleep + appetite red. Weight lossOne 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).BehaviourArgue with husband, stay in
14Unhelpful thinking styles - 1 Typical thoughtsBias against myselfOverlook my strengthsFocus on my weaknessesDownplay my achievementsMy own worst criticPutting a negative slant on things(negative mental filter)See things through dark tinted glassesPut a negative slant on thingsHaving a negative view of the futureJump to the very worst conclusionsCatastrophisingMake negative predictions about the futurePredict that things will go wrong
15Unhelpful thinking styles - 2 Typical thoughtsMind-readingNegative view of how others see meMind-read what others think of meAssume that others don’t like me/judge me badlyBearing all responsibilityTake things to heartTake the blame ++Feel overly responsibleMake extreme statements/rulesUse the words “must”, “should”, “ought” and “always”/”never” a lot.High standards ++
16Task: (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.
17Key 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 moreHelpful/balanced thoughts are crowded out
18The impact of extreme thoughts What is unhelpful about extreme thoughts1. “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
19How does CBT work?Identifies – and then challenges extreme and unhelpful thoughtsGathers evidence for and against the thoughtCome up with a balanced conclusionOvercome reduced activity, avoidance and unhelpful behaviours.More next session
20Psychodynamic 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 approachLater developments by Jung, Adler, Klein, Anna Freud, Winnicott - different schools.
21Psychodynamic psychotherapy Much more of an emphasis on the past, particularly on childhood eventsIt emphasises the importance of mental representations of early life experiences in the present & the impact they have on current relationships.
22Psychodynamic 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.
23Psychodynamic psychotherapy Freud was a major figure in 20th Century thought.Neurologist.Outlined three theories to account for mental processes.Topographical, structural, developmental.
24Psychodynamic psychotherapy Topographical theory & unconscious mind.Conscious and unconscious mindUnconscious thoughts and feelings which influence behaviour.Thought may be unconscious because it is consciously suppressed or unconsciously repressed.
25Psychodynamic 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
26Psychodynamic psychotherapy Developmental Model - series of stages.Oral - first year.Anal - 2nd, 3rd years.Genital - 3-5th yearTheorised that problems occurred at these times cause characteristic mental symptoms later on e.g. OCD and anal phase.
27Psychodynamic 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
28Psychodynamic 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!
29Psychodynamic Psychotherapy Defence mechanisms - major one is repression.E.g. choosing not to remember you have an exam next week.Reaction formation, denial, rationalisation, projection.
30Psychodynamic 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 dreamsLie/sit down e.g. on a couch or bed– long silences
31Psychodynamic Psychotherapy Working allianceTransference: how the patient reacts to youCounter-transference: how we react to the patient
32CounsellingAims 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 problemsLife crises & problem solving (HIV, Cancer, bereavement in NHS).
33Counselling 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 genuinenessAvoids providing “answers”
34Family therapyAims to see if and how the problem of the identified patient is maintained by the needs of the family.A number of schools (Systemic).
35Family therapyUsually 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.
36Case example Cameron is 32 and is depressed. Already on medication from GP.Lives with his mother; he doesn’t work.Witnessed alcoholic father/ domestic abuseNow has panic attacks on leaving houseTook an overdose of paracetamol.Upset that his sister is leaving for New Zealand.
37Task – 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?
38FeedbackAny 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?