week 12/13 - psychological therapies

• Psychotherapy


  Often used interchangeably with "psychological therapy", i.e. "psychotherapy" is sometimes used to refer to all forms of psychological therapy. It is also used to refer to a specific type of therapy called "psychodynamic psychotherapy"
• Clearest use of terminology


  "Psychological therapy" to describe psychological treatments as a whole and "Psychodynamic psychotherapy" for that specific type of therapy
• Counselling


  Less technically complicated than other (more formal) types of psychological treatment and relatively low level of qualification required. It ranges from sympathetic listening to structured ways of problem-solving and is usually short-term and focused on a specific issue. Main aim: help client find their own solutions to problems, while being supported to do so and being guided by appropriate advice
• Formal psychological therapies


  • Problem solving therapy
  • Cognitive behavioural therapy
  • Psychodynamic psychotherapy
  • Cognitive analytic therapy
  • Dialectical behavioural therapy
  • Systemic therapy
• Types of psychological therapy


  • Individual therapy
  • Couple therapy
  • Family therapy
  • Group therapy
  • Small group
  • Large group
• Stepped Care Model


  • Level 1: Basic information about disorder and self-help AND Discussion within standard medical appointment, book(let) or internet
  • Level 2: Often group treatment or computerized delivery of psychological therapy
  • Level 3: Usually 1:1, face-to-face
  • Highest level: Intensive therapies for patients with complex needs
• Cognitive behavioural therapy (CBT)


  • Widely used type of psychological therapy with a strong evidence base. It integrates cognitive and behaviour therapies and requires specialist training. It is a structured type of therapy delivered over a set number of sessions, usually 10-15. Although used in many different situations, the principles of CBT remain the same. Some of the basic approaches used in CBT can be used by people without specialist training, e.g. relaxation, graded exposure and anxiety management. CBT is normally limited to a set number of sessions.
• Key principles of CBT

  • Central premise: thoughts, feeling and actions are interdependent, changing one will affect the others
  • Focuses on the here & now: understanding and managing maladaptive thinking and behaviour
  • Goals: symptom relief and development of new skills to sustain and maintain recovery
  • Structured course of sessions: limited to a planned number of 10 - 15 sessions with overall plan for course of therapy with beginning, middle and end
  • Collaborative: patient is active partner in care
  • Scientific and empirical: patient tests reality for themselves
  • Patients undertake homework between sessions: practice/evaluate new ways of thinking and behaving
  • Symptoms, cognitions and behaviours are recorded by patient: helps to make links and identify opportunities for change
  • Behavioural experiments used to test out beliefs and predictions
• Indications for CBT


  • Depression
  • Anxiety disorders and Post-traumatic stress disorder (PTSD)
  • Eating disorders
  • Bipolar affective disorder
  • Psychosis
  • Personality disorder
  • Sleep disorders
  • Substance use disorders
• Cognitive therapy


  Based on idea that the patient's difficulties are not caused by life events, but by the view the patient takes of events. If we can help the person to change the way they think about events, their impact may be lessened, and the patient's symptoms improved.
• Key cognitions to consider in cognitive therapy


  • Negative automatic thoughts
  • Underlying assumptions
  • Core beliefs or schemas
• Cognitive distortions


  • Black and White thinking
  • Emotional Reasoning
  • Mind-reading
  • Mental filter
  • Catastrophising
• Alternative thoughts to cognitive distortions

  • What is the evidence?
  • Just because if feels bad, does not necessarily mean it is bad
  • Am I noticing only the bad stuff? Am I dismissing the positives?
  • There is nuance. Where is this on the spectrum?
  • If it was someone else in this position, what would be the most likely thing to happen?
• Stages of cognitive therapy


  1. Identify maladaptive thinking

  2. Challenge maladaptive thinking

  3. Devise more realistic alternatives

  4. Test out these alternatives
• Behavioural therapy


  Addresses abnormal behaviours that persist because of certain actions of the patient or other people that produce immediate relief of distress but nevertheless prolong the disorder.
• Commonly used techniques in behavioural therapy


  • Distraction
  • Relaxation training
  • Graded exposure
  • Response prevention
  • Thought stopping
• Behavioural experiments


  A CBT technique that challenge people's unhelpful beliefs and behaviours. Patients are supported gathering information to test the accuracy of their problematic belief or to test the benefit of a more helpful alternative belief.
• Psychodynamic Psychotherapy


  Dynamic therapies, including psychoanalysis or psychodynamic psychotherapy and group analysis are derived from the psychoanalytic principles and practice of Sigmund Freud and those who have subsequently developed his ideas. Most therapies that conceptualise an unconscious mind affecting our perceptions and actions can be considered part of the school of dynamic psychotherapies.
• Rationale for psychodynamic psychotherapy


  Traumatic experiences, particularly those in early life, give rise to psychological ("internal") conflict. The greater part of mental activity is unconscious: conscious mind is protected from the experience of this conflict by inbuilt defences, designed to decrease 'unpleasure' and to diminish anxiety. These defences are developmentally appropriate but continuation into adult life results in either psychological symptoms or in a diminished ability for personal growth and fulfilment. Psychological conflict can be examined with regard to the anxiety itself, the defence, and the underlying wish or memory. The individual's previous family and personal relationships will have symbolic meaning and be charged with powerful emotions. Representations of these relationships will emerge during therapy and provide a route towards understanding and change.
• Long term psychodynamic psychotherapy


  Big commitment for patient and therapist. Aims to change longstanding thinking/behaviour.
• Traumatic experiences


  Give rise to psychological ("internal") conflict
• Unconscious mental activity


  The greater part of mental activity is unconscious
• Conscious mind


  Protected from the experience of this conflict by inbuilt defences, designed to decrease 'unpleasure' and to diminish anxiety
• Defences


  Developmentally appropriate but continuation into adult life results in either psychological symptoms or in a diminished ability for personal growth and fulfilment
• Psychological conflict examination


  1. The anxiety itself

  2. The defence

  3. The underlying wish or memory
• Previous family and personal relationships


  Will have symbolic meaning and be charged with powerful emotions
• Representations of relationships


  Will emerge during therapy and provide a route towards understanding and change
• Long term psychodynamic psychotherapy

  • Big commitment for patient and therapist
  • Aims to change longstanding thinking/behaviour that contributes to relationship and mental health problems
  • Usually sessions several times a week for a year or more
  • Evidence base less strong than for CBT
  • Long term psychotherapy is less and less available in NHS services
  • Clear need in some patient with complex needs unresponsive to brief therapies
• Techniques used in long term psychodynamic psychotherapy


  1. Patient encouraged to allow mind to wander freely from a starting point that is relevant to the problem at hand

  2. Free association and recall of dreams, often used to recall previously repressed memories

  3. Interpretation of transference and control of countertransference
• Defence mechanisms


  Unconscious resources used by the ego to decrease internal stress ultimately
• Types of defence mechanisms

  • Primitive/Immature
  • Neurotic
  • Mature
• Primitive/Immature defence mechanisms


  • Projection
  • Regression
  • Splitting
• Neurotic defence mechanisms


  • Displacement
  • Rationalisation
  • Repression
• Mature defence mechanisms


  • Sublimation
  • Humour
  • Altruism
• Cognitive analytic therapy


  Time-limited, therapy that looks at how people get "stuck" in the way they think about themselves and others, and the patterns of behaviour that arise from this. Combines techniques from analysis and cognitive therapy. Strongest evidence in personality disorder.
• Interpersonal therapy


  Used in depression and based on idea that problems in relationships with family and friends may be at the root of depression
• Dialectical behavioural therapy


  Specialist therapy based on CBT, most often used in emotionally unstable personality disorder. Aims to help patient identify difficult emotions and learn to manage them. Often includes crisis coaching.
• Systemic therapy


  Helping families to identify and change unspoken rules and distorted ways of communicating.
• Person-centred approach


  Idea that the most important factor in therapy is the relationship between client and therapist. Three core conditions that therapists must have: Unconditional positive regard, Empathy, Congruence (genuineness)
• Therapeutic relationship


  All interactions with a patient can have a therapeutic effect. The therapeutic relationship is central to the practice of psychotherapy.