Psychotherapy

PRINCIPLES

Factors common to all psychotherapies

 Therapist is credible + plausible rationale, behave in empathic and interested fashion, instils
hope of improvement (key). Therapy is a safe place, and is a collaborative effort.
 Select right therapy for right patient (good outcomes require motivated patient; pros + cons),
prepare patient for therapy (so they know what to expect), ensure accessibility
 Stepped care model:
o 0 = not identified (60%), 1 = GP/ assessment/ psychoeducation/ monitoring (20%), 2 =
low intensity interventions e.g. IAPT, cCBT, group CBT, guided self-help (9%)
o 3 = high intensity e.g. individual CBT (6%), 3 = complex/specialised (5% of prevalence).
Both step 3+4 provided at secondary MH services.

SPECIFIC PSYCHOTHERAPIES

Simple psychotherapies

 Psychoeducation – provide information to help people understand and cope will illness. Can be
individual or in groups. Usually takes person’s strengths and coping strats into account.
 Counselling – loose term to describe the activity whereby people are helped to overcome or
cope w life’s problem. Counsellor is the supporter and facilitator of emotional expression, soruce
of information, and someone whose ideas can be bounced. Usually non-psychiatric.
o Indications: short-term effectiveness in mild neuroses and brief stress-related disorders
(when anxiolytics not required). Also for current stresses and problems.
 Supportive psychotherapy – formalised version of “good friend” (listening, accepting, and
encouraging) – they aim to help people cope with adversity or insoluble problems over sustained
period, not to produce change.
 Problem-solving therapy – mix of counsel + CBT  helps patient learn to actively deal w life’s
problems by specifying them, select an option for tackling each one, try out solutions, then
review effects. Can be given by nurses or GPs.
o Indications: mild neurotic disorders and mild DD.

Cognitive therapies

 Focuses on thoughts and assumptions – promoting the

theory that we respond to our interpretation of events,
not raw events alone. Therefore, cognitive changes
required to produce emotional + behavioural change.
 Aim is to correct inaccurate or helpful ways of thinking
 improve mood, reduced anxiety, and return to
normal behaviour
 Hot crossed bun model illustrate the interactions
between thoughts, feelings, behaviours, and body
sensation. Any situation will trigger a set of internal and external reactions that can result in
negative experience that create a vicious cycle that maintain or increases avoidant or negative
patterns.
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 BECK suggests a person who habitually uses depressed or anxious cognitive distortions will be
more likely to become distressed when faced w minor problems. These lead to distortion within
the cognitive triad of the SELF, WORLD, and the FUTURE.
o Examples of cognitive distortions:
 All-or-nothing thinking
 Overgeneralisation
 Personalisation (self-blame) and blaming others
 Jumping to conclusions (including “mind reading” – assume someone is thinking
negatively just from their behaviour)
 Arbitrary inference (draw conclusions w little evidence)
 Emotional reasoning (I feel it, therefore must be true)
 Disqualify any +ve
 Mental filtering (concentrate on negative aspect only)
 Selective abstraction (dwelling on INSIGNIFICANT detail while ignoring important
features)
 Magnification (any faults) and minimisation (any +ve) e.g. catastrophizing =
assign greatest emphasis on most terrible outcome.
 Core components of CBT: active, PRESENT-focused, lasting 12 weeks (max: 24 weeks).
o Therapist provide detailed description of problem, paying attention to cognitions
(thoughts) the patient experience w problem (“grounded Hx” + assessment
tools/questionnaires  “how are things now and what are goals for therapy”) – always
check the mood and review it at the start of session, before setting agenda
o Therapist provide explanation (formulations) of role of cognitions in perpetuating the
problem (“how the problem formed and what is keeping it there?”)
 Developmental model = early experiences form core beliefs  negative
automatic thoughts. Therefore, thinking pattern can be unlearned.
 Maintenance model = negative automatic thoughts + actions + coping maintain
the problem
o Tx plan w clear goals and objectives + progress monitoring
o Each session breaks difficulties into different areas (thoughts, feelings, behaviours) for
analysis
o Patient does homework in between and report effect next session (e.g. thought diary)
o Patient taught to become aware of and challenge negative and inaccurate cognitions
and practise thinking more helpful or accurate ways (behavioural experiment)
o Techniques:

Patient 1st learn to ID cognitive distortion from present/recent C – change thoughts and actions
experience (use daily diaries + questioning)  H – homework (practice makes perfect)
Patient records such ideas and then learns to examine A – action (DO it)
evidence for/against them + test out these beliefs in real life N – need (pinpoint problem)
 G – goals (move to them)
Patient encourage to restart pleasurable activities that they E – evidence (shows CBT works)
have given up (even if they don’t enjoy them yet…)
 V – view (events from another angle)
In this way, cognitive restructuring occurs – patient can ID, I – “I can do it” (self-help approach)
evaluate, and change distorted cognitions and associated E – experiences (test out beliefs)
behaviours W – write it down (to remember progress)
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o Modalities = individual (1:1), group, bibilotherapy (self-help) = Reading Well Books on

Prescription scheme, and CCBT = computerised (MoodGym, FearFighter)
 Indications:
o General: patients prefer psych intervention (alone or in addition to drugs); target
problems present for CBT (i.e. extreme unhelpful thinking; reduced activity;
avoidant/unhelpful behaviours); no improvement/partial improvement on meds; or S/E
to prevent sufficient dose of meds over adequate period.
o Specific: depression, GAD, panic disorder, phobia, OCD, PTSD, hypochondriasis, bulimia
 CAUTION:
o Severe depression, poor concentration, difficulties talking about feelings, patients
focused on childhood events, poor motivation to change

Behavioural therapies

 Aim to alter behaviour 1st w the theory that if these change, then our thoughts and emotions will
also evolve. Central idea is adaptive behaviour can be learned and maladaptive ones can be
unlearned.
 Effective in anxiety disorders (esp. PHOBIAS and OCD) and behavioural problems in LD.
 Key component = EXPOSURE. Either patient is re-exposed to situation or behaviour that they
have come to avoid (e.g. agoraphobic and house leaving) OR they learn to stop inapt, excessive
response (e.g. recurrent handwashing in OCD)
 Flooding = sudden+prolonged re-exposure until habituation = too unpleasant for routine use.
o Imaginary version is called “implosion”
 Graded exposure (systematic desensitisation) are more commonly employed.
o Indication: PHOBIAS
o The therapist assess problem behaviour, its antecedents and consequences. Then
explained to patient the nature of Tx and rationale.
o Start with least fearsome  real or imagine stimuli; perform relaxation techniques until
anxiety extinguished
o A step-by-step programme is developed jointly with patient, including homework tasks
that re-expose patient to a tolerable level of anxiety.
o Over each exposure, the patient is desensitised to stimulus.
o Subsequent lessons review progress and problems, and set next series of tasks.
 Other types of behavioural therapy: social skills training, assertiveness training and relaxation
training
o Social skills training (uses videos to define patient’s behaviour to standard social
encounters, then teach them more apt behaviour by modelling, video-feedback, and
roleplay)  in patients w social deficits due to psych disorder.
o Assertiveness training (modelling and role play)  in patients w lack of social skills and
assertiveness
o Muscle relaxation training (system of exercise and regular breathing to relax individual
muscle group, and link the relaxed state w pleasant, imagined scenes)  in
mild/moderate anxiety
o Response prevention (exposure to anxiety-provoking stimuli, patient subsequently
prevented from carrying out compulsion rituals)  in OCD
o Thought stopping (patient asked to ruminate and then taught to stop negative
anticipatory/obsessional thoughts before they gather momentum e.g. arranging an
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intrusion = snap elastic band on wrist)  in OCD and undesired sexually deviant/
intrusive thoughts.
o Token economy (reward tokens that can later be exchanged for privileges; problem is
that patient become mercenary and behave well only for exchange for tokens, this
poorly prepare patients for the real world where rewards are subtle and delayed)
used in CHILDREN, low IQ, addictive disorder, chronic psych disorders
o Aversion therapy/covert sensitisation (punish people for behaving wrongly;
CONTROVERSIAL and generally ineffective unless patients TAUGHT more apt behaviour)
 EtOH dependence syndrome (dilsufiram to induce nausea = patients just stop taking
the pills instead); sexual deviations.

Cognitive behavioural therapy (CBT)

 In practice, cognitive and behavioural Tx are usually combined

 In mild + moderate depression: CBT = SSRIs
 In panic disorders + phobic anxiety: CBT > most Tx (benefits are more persistent than anxiolytics
and avoid S/Es)
 In neuroses (somatoform disorders and OCD), CBT is efficacious.
 In bulimia, a modified form of CBT is employed.
 In schizo +ve Sx (psychosis), some effect shown using CBT
 ?CBT role in preventing relapse in BAD…

Psychodynamic (psychoanalytic) therapies

 Have very little place in modern psychiatry and in the NHS

 Concerned w origin and meaning of Sx, not necessarily the P/C.
 Based on view that vulnerability comes from early experiences and unresolved childhood issues
 Therapist makes interpretation about what patient says and draw connections between events
and feelings. During therapy, patients gain insight into emotions and their behaviours as a result
of these interpretations. Therapeutic effect may emerge directly form greater self-
understanding, and reinforced by new patterns of behaviour that arise form it.
 It is very time-intensive (up to years)
o “Brief psychodynamic psychotherapy” = more feasible course of 10-20 session where
therapist have more active role and focus on particular issues. Efficacy in depression.
 Indications: mainly for people w personality difficulties esp. recurrent problems w R/S. Role in
chronic neuroses and DD that are resistant to other treatments
 Contraindication: antisocial and paranoid PD; psychosis.
 Principles are important
o Transference
 Patient projects feeling about formative or other important persons onto
physician (e.g. psychiatrist is seen as parent; this can be seen as
unexpected/inapt behaviours such as affection or threatening self-harm if extra
appointment not given)
o Counter-transference
 Doctor projects feelings about formative or other important persons onto
patients (e.g. patient reminds them of younger sibling; doctors should be aware
of emotions evoked by patients and understand their origins, so as to not affect
ability to Tx patient)
o Psychological (ego) defence mechanisms
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Immature defences
Acting out Express unacceptable feelings/thoughts through action e.g. tantrums
Denial Avoid painful reality
Displacement Redirect emotions or impulses to neutral person/object
Dissociation Temporary, drastic change in personality/memory/consciousness/ motor
behaviour to avoid emotional stress. Patient has incomplete/no memory
of traumatic event. E.g. victim of rape appears numb and detached when
exposed to abuser.
Fixation Partially remaining at a more childish level of development (vs regression)
e.g. surgeon throws tantrum in OT as lase case ran late.
Idealisation Express extreme +ve thoughts of self and others, while ignoring –ve
thoughts. E.g. patient boasts of his doctors accomplishments while
ignoring flaws.
Identification Largely unconscious assumption of characteristics, qualities, or traits of
another person/group. E.g. a med student starts putting stethoscope in
pocket like his favourite consultant, instead of the way he did before
Intellectualisation Using facts and logic to emotionally distance oneself e.g. cancer patient
focuses on rates of survival during therapy session
Isolation (of affect) Separate feelings form ideas and events. E.g. describe murder in graphic
detail with no emotional response
Passive aggression Demonstrating hostile feelings in non-confrontational manner; showing
indirect opposition.
Projection Attributing unacceptable internal impulse to external source (vs
displacement) e.g. a man who wants to cheat on his wife accuses his wife
of being unfaithful
Rationalisation Proclaim logical reasons for action (actually performed for other reasons)
to avoid self-blame. E.g. after getting fired, claims job was not important
Reaction formation Replacing a warded-off idea or feeling by (unconsciously derived)
emphasis on its opposite (vs sublimation). E.g. a patient w libidinous
thoughts enter monastery
Regression Involuntarily turning back the maturational clock and going back to earlier
modes of dealing w world (vs fixation) – seen in children under stress e.g.
punishment, illness, birth of new siblings (e.g. bedwetting after
hospitalisation)
Repression Involuntarily withholding idea or feeling from conscious awareness (vs
suppression) – e.g. 20 year old does not remember going to counselling
for his parents’ divorce
Splitting Believe all patients are either good or bad (dichotomy), at different times
due to intolerance of ambiguity. SEEN commonly in BPD.
Mature defences
Sublimation Replace unacceptable wish w course of action similar to wish but doesn’t
conflict w one’s value system (vs reaction formation). E.g. teenager’s
aggression towards father is redirected to perform well in sports
Altruism Alleviate negative feelings via unsolicited generosity
Suppression Intentionally withholding an idea or feeling from conscious awareness
(v.s. repression); temporary. E.g. choosing not to worry about big game
until it is time to play
Humour Appreciating amusing nature of anxiety-provoking/adverse situation e.g.
nervous med student jokes about exam.
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Group therapies

 Group interactions change the therapeutic environment and provide alternate space to explore
interpersonal R/S. The therapy delivered can be any type.
 Technique:
o 6-8 people (balanced for sex and age); closed or open to new members
o Forming  storming  norming  performing throughout the 18 months
o First = settling-in (best behaviour by members, seeking to be loved by therapist, and
expecting directive counselling)
o Next = conflict – each person strive to find their place in group other than dependency
on leader.
o Then, intimacy – knowing that expressing –ve feelings don’t lead to rejection. Group
starts to work together.
 General indications:
o Enters voluntarily, high expectation of the therapy, and adequate verbal skills.
 Specific indications:
o PD, addictions (Drugs + EtOH dependence = 12-step models are all group therapies),
victims of childhood sexual abuse, people w difficulty socialising, major medical illnesses
(e.g. breast cancer).
 CONTRAINDICATION:
o Severe depression, acute schizo, hypochondriacs, extreme schizoid personality (cold,
aloof, hypersensitive introverts)
o Extreme antisocial behaviour, perpetrators of abuse (esp. paedophilia) – as group can
condone or normalise past thoughts or actions rather than weaken them.
 Therapeutic communities (TCs)
o Popular for IVDU and PDs in USA and EU.
o Rationale: benefits of peer-feedback (group therapy) magnified in microcosm of TCs.
Also provide safe environment for those w complex needs.
o It is more beneficial if it is 12 months; and is better than residential therapy (prison) in
terms of re-offending/ re-using drugs.
o After TCs – aim to continue aftercare.

Family/systemic therapies

 Aim to alter behaviour 1st w the theory that if these change, then our thoughts and emotions will
also evolve. Can be in form of psychodynamic, behavioural etc.
o Systemic – focuses on beliefs, patterns, and meanings w no objective truth
o Structural – focuses on family rules and hierarchies
o Solution-focused – focus on setting a goal and for family to collaborate to reach it
o Narrative – focus on family “scripts” which are ways to live; problems emerge when
individuals deviate from “dominant family narrative”; therapists help family develop
new narrative.
o Transactional –focus on problem actually serving a purpose (e.g. difficult child prevents
parents from divorcing) and interplay between family (transactions). Family given tasks
by therapist to challenge these roles.
 Aim to reduce “expressed emotion” (e.g. schizo, AN, and even medical conditions e.g. CF)
 Some efficacy in children w conduct disorder, substance misuse, eating disorder, schizo, and
BAD.
 Dysfunction family patterns:
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o Triangulation – when parents are in conflict, each demands child to side with them. If
child sides with one, they are automatically considered to be attacking the order. Child is
paralysed in a no-win state where every move is a perceived attack on a parent.
o Scapegoating – when individual singled out by family as sole cause of family troubles;
serve to temporarily bury conflicts that family fear will overwhelm them
o High EE – hostility, emotional over-involvement, critical comments, contact time (seen
during family interview)

Play and art therapies

 Variety of approaches to therapist-pt communication

 Play therapy: usually children (y 3-11, more frequently in less verbal/ those who play more) to
communicate their experiences and reactions through actions, allowing them to express
emotions and develop understanding of themselves and others, resolve psychosocial challenges,
and gain acceptance. This builds social integration and emotional regulation.
o Directive play = structured guidance where therapist leads play toward an identified
difficulty to work through. It is comparable to CBT/behavioural approach.
o Non-directive play = child leads = encourages child to play freely w/o intrusion, and in
doing so recognise and solve problems. It is comparable to psychodynamic therapy.
o Good effects on social functioning after sexual abuse, neglect, and in autism.
o Play as Dx tool e.g. playtime routines (school observation) assessment of ADHD
(impulsive vs take turns; play with others vs sit alone)
 Art therapy: uses art for self-expression (where verbally it may be hard) and reflection. Chief aim
= effect change and growth in self-esteem, through a safe and facilitating environment, by using
art as a medium. Can be done in all age groups, and in LD, palliative care, and in prisons. And
done for a variety of reasons (promote interaction, coping skills e.g. in anorexia and dementia).
The therapist evaluates art while client interprets the art. NICE says always consider non-drug Tx
for depression.

HYBRID THERAPIES

Cognitive analytical therapy (CAT)

 Combines cognitive + psychoanalytic approaches

 Mainly used in depression

Interpersonal therapy (IPT)

 Uses cognitive, behavioural, and psychodynamic concepts and techniques to focus on pt R/S and
problems arising from them
 Some evidence to suggest equal efficacy to CBT in depression and bulimia

Dialectical behavioural therapy (DBT)

 Developed for people with borderline personality disorder

 Combines psychoeducation + behavioural skills training, creating strong therapeutic R/S

Mentalisation-based therapy

 Mentalisation based therapy is used for people w BPD – helps people understand thoughts and
feelings relate to mental state and not just in themselves but also others.
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Eye movement desensitisation and reprocessing (EMDR)

 Used in PTSD

COMPARING THERAPIES

 Psychotherapy should be considered as an option when assessing MH problems. It is better than

no treatment.
 Patients who are adjusting to life events, illnesses, disabilities, or losses may benefit from brief,
SIMPLE therapies such as counselling. Counselling effectiveness in mixed anxiety/depression,
most effective at targeted groups e.g. postnatal mothers, bereaved.
 PTSD are helped by psychotherapy (trauma-focused CBT), but routine debriefing following
traumatic events are not recommended.
 Depression may be helped (but not often cured) by CBT or IPT.
 Anxiety disorders (agoraphobia, panic, social phobia, OCD, GAD) all benefit from CBT
 Eating disorders can be Tx w psychotherapy. Best evidence in bulimia for CBT, IPT, and family
therapy for teens. Tx usually includes psychoeducation. For anorexia, there is little evidence for
the best type of therapy. Early-onset anorexia may indicate family therapy v.s. later-onset may
indicate individual therapy, but evidence is weak.
 Psych intervention (esp. CBT) should be considered for somatic complaints w psych component
 For personality disorders, structured psychotherapy can contribute to its LT Tx. This includes
DBT, psychoanalytic day hospital programme, and therapeutic communities.

SOCIAL TREATMENT

Social interventions during psych care

 Accom + $$ problems – help by rescheduling debts, housing matters etc. Citizen’s Advice
Bureau is a voluntary organisation that provide this form of support.
 Family support and education (even if specific family therapy not used).
 Home visits, attendance at day centres, put person in touch w self-help group  all these
combat social isolation
 Chronic psych disorder  damages self-esteem and occupational skills  rehab by continuing
support above and extensive interventions e.g. sheltered accom + supported employment.

Wider social problems

 Public education – to raise awareness and decrease stigma

 Social policy – to reduce EtOH consumption, determine extent of compulsory treatment
 Primary prevention: prevent domestic violence, NAI, and unemployment