Psychological therapies Dr Chris Williams

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.

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?

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?

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.

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

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.

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

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.

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

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.

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

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

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

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 ++

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.

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

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

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

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.

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.

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.

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

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.

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

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.

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

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!

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.

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

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

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).

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”

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).

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.

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.

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?

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?

Any questions

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