psychological therapies dr chris williams todays objectives. you will: gain an overview of the range...

Psychological therapiesPsychological therapiesDr Chris WilliamsDr Chris Williams

Today’s objectives. You will: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.

Task - at endTask - 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 Psychotherapy: Group discussiondiscussion

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?

PsychotherapyPsychotherapy

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 documentKey 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 modelThe CBT model

Aims to reduce symptoms by changing specific behaviours and thoughts which maintain specific symptoms.

Name associated with it is Professor Aaron Beck.

CBT: a simple messageCBT: a simple message

What you think affects how you feelWhat you think affects how you feel

Thinking Feelings

Thinking Behaviour

What you think affects what you doWhat you think affects what you do

The CBT modelThe 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

CBT treatmentCBT 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

Experiment:Experiment:(in pairs – 5 minutes)(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 timeFeedback time

Life Situation, relationship and Practical Problems

Altered Thinking

Altered Feelings Altered Physical Symptoms

Altered Behaviour

The Five Areas Assessment ModelThe Five Areas Assessment Model

Life Situation, relationship and Practical Problems£2500 debt, arguments with husband

ThinkingI’m useless,

Everything’s wrong

FeelingsLow, anxious,

angry

Physical Sleep + appetite red. Weight loss

BehaviourArgue with

husband, stay in

A Five Areas Case Summary -1A Five Areas Case Summary -1

Unhelpful thinking styles - 1Unhelpful thinking styles - 1Unhelpful thinking style 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 - 2Unhelpful thinking styles - 2Unhelpful thinking style 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)Task: (in pairs)Q. What is your first thought?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: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 moreHelpful/balanced thoughts are crowded out

The impact of extreme The impact of extreme thoughtsthoughts

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

How does CBT work?How does CBT work?

Identifies – and then challenges extreme and unhelpful thoughts

Gathers evidence for and against the thought

Come up with a balanced conclusionOvercome reduced activity, avoidance and

unhelpful behaviours.More next session

Psychodynamic psychotherapyPsychodynamic psychotherapyExploratory 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.

Psychodynamic psychotherapyPsychodynamic 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 psychotherapyPsychodynamic 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 psychotherapyPsychodynamic psychotherapy

Freud was a major figure in 20th Century thought.

Neurologist.Outlined three theories to account for

mental processes.Topographical, structural, developmental.

Psychodynamic psychotherapyPsychodynamic 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 psychotherapyPsychodynamic 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 psychotherapyPsychodynamic 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 psychotherapyPsychodynamic 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 PsychotherapyPsychodynamic 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 PsychotherapyPsychodynamic 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: Psychodynamic Psychotherapy: what does it look like?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 PsychotherapyPsychodynamic Psychotherapy

Working alliance

Transference: how the patient reacts to you

Counter-transference: how we react to the patient

CounsellingCounselling

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).

CounsellingCounselling

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”

Family therapyFamily 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 therapyFamily 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 exampleCase 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 minsTask – 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?

FeedbackFeedback

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 questionsAny questions

The EndThe End

Next week:Self-help and PsychotherapyProblem solving approachesCBT- focus on reduced activity and

identifying extreme and unhelpful thoughts