Intervention Flashcards
Interpersonal therapy general
Short term
Improve relationships and create social support
Grounded in ATTACHMENT theory, seek for understanding NOT changing
Either modify relationships or change expectations
Effective for depression and eating disorders
Given thus attachment style, personality, ego, defence mechanism, life experiences, how can they be helped to improve here and now relationships and build more effective network
Emphasise social relationship over therapeutic relationship - different from dynamics therapy
Transference experience helps w informing potential problems and predict therapy outcomes
IPT essential characteristics (4)
(1) focused on relationships
- improve communication or change expectations, OR
- build or better use of support network
(2) use relationship to conceptualise distress
- interaction between attachment and stressors is critical (if the person securely attached, they can deal with crisis well)
- when crisis occurs, those who cannot ask for care, and get care, will become more prone to develop symptoms
(3) time limited - 8-20 sessions
Assessment 1-3
Middle 4-12
Concluding 1-2
Maintenance phase - mutual agree between therapist and patient
Clinician has active role and maintain focus of therapy
(4) do NOT address transference relationships
IPT problem areas (3)
1) Grief loss
Understand the experience, NOT pathologise
Facilitate mourning process
Reconnect w others
Develop 3d picture of the loss person, identify good and bad characteristics
2) Interpersonal disputes
Understand communication patterns
The way they conceptualise conflict
Do NOT require relationships being repaired
Patient to make active and informed decision
Learn to communicate their needs
Role play to reinforce new communication
3) Role transitions
Life cycle changes
Loss of important social supports, demands for new skills
Help transition from old role, including experience grief over loss
Develop realistic and balanced view
Develop new social supports and skills
Interpersonal conceptualisation - model of self
Self competent (1)
Not self competent (2)
Will provide care (A)
Won’t provide care (B)
1A secure
Both give and receive
Self competent and believe care availability - help reduce stress
2A Preoccupied
Seek care constantly, when needs are not met, want more care. Lack of ability to care for others —> poor social network; hard to ask for help, more vulnerable
1B Dismissive
Dominant and controlling
Quick to reject others
Self confidence but marked deep insecurity
Drives to engage in relationships despite unsatisfactory nature
2B fearful
Believe other will not provide care
Avoid becoming close
Poor social connection
Avoiding asking for help
Most vulnerable
Transference vs countertranference
Transference: redirection of feelings about a person onto someone else (client projecting their feelings about someone onto the therapist)
Countertransference: redirection of the therapist’s feelings toward the client
IPT initial sessions
Initial:
- assessment (determine whether IPT is a good option)
- guided by evidence, attachment style, motivation, insight
- diagnosis should be made - well suited for mood and anxiety disorders
- suitable for those w work conflicts and marital issues
- make hypothesis for client’s model of relationships
- preoccupied and dependent may find it hard to form relationships and end relationships
- dismissive and fearful may find it hard to trust and relate (may need more initial)
- plan for problems that may arise later
4 specific tasks:
- conduct an interpersonal inventory
- collaboratively develop an IPT summary
- work collaboratively w the patient to determine area of focus
- develop treatment agreement
Interpersonal inventory
- interpersonal circle (place 6-8 people for closeness)
- ask how things have changed, how they would like it to look
Interpersonal formulation based on biopsychosocial/ cultural/ spiritual model - not showing to client
Interpersonal summary: collab project - in client’s own words, why they have problems, listing their own strengths, writing their goals <— this the road map for therapy
Treatment agreement
- Explain rationale
- Flexible time frame to be negotiated
- Number, frequency, duration, focus of therapy, role of therapist, client’s responsibility
- Contingency planning eg lateness, illness
IPT middle sessions
Work together to address problems
- identification of specific problems
- exploration oft perception
- brainstorming for possible solutions
- implementing proposed solution
- review progress and encouragement
Technique: interpersonal incidents and communication analysis
- analyse patterns of communication - help communicate more effectively
- client describe a specific interaction to understand the client’s communication and what triggers the problems
Use of affect
- connect w emotions - more likely to change behaviour
- incongruence between shown emotions and reported emotion - examine this
- process affect (during therapy, when they describe the events) vs content affect (in the past, at the time of events)
Problem solving 4 components:
- detailed examination of problem
- generate potential solutions
- select a course of action
- monitor and refine solution
Solution to be based on client’s own ideas
IPT maintenance
End of therapy is NOT the end
Agree to have sessions in the future
Always discuss maintenance treatment
Alternatives exist for maintenance treatment: scheduling maintenance sessions monthly or longer, ask to contact therapist if problems occur, plan to contact others in the future if you’re not available, specific agreement to be created
Two-phase treatment to help prevent relapse
IPT key mechanisms (4)
Enhance social support
Decrease interpersonal stress
Process emotions
Improve interpersonal skills
Motivational interviewing general
Effective for substance use
Develop motivation to change will
- increase engagement in therapy
- increase symptoms improvement
Collaboration
Acceptance
Compassion
MI THEORY
2 components
1. Technical (the intervention)
2. Relational (therapeutic relationships)
OARS
- open questions
- affirmations
- reflections
- summary statement
—> change talk, reduce sustain talk, resolve ambivalence to change
Therapist:
- non judgemental
- collaborative
- acceptance space
- compassion
4 pillars:
- Compassion
- Collaboration
- Acceptance
- Evocation
MI Application
Use core interview to elicit intrinsic motivation for behaviour change
Using the client’s strengths and resources to facilitate behaviour change.
4 major processes:
- engaging: establish alliance, determine how motivated by degree of change and sustain talk
- focusing: narrow discussion to make collaborative decision
- evoking: eliciting patient own motivation and commitments
- planning: formulate specific plan m, articulate steps to achieve change
MI engaging
Establish strong alliance
Avoid promote disengagement:
- assessment - passive stance for patient
- expert: client defensiveness
- premature focus: not ready for change, struggle
- labelling: judgemental
- chat: insufficient direction
Use open-ended questions
Reflective listening
Affirmation: recognise efforts, foster beliefs
Summary statement
MI focusing
Prioritise
Agenda mapping with client - ask them where they want to start
Assist if they cannot
Building their confidence
MI Evoking
Elicit reasons to change:
- recognising change talk
- using evocative questions and reflection
- employ important confidence ruler
- use decisional balance
- exchange information
- explore goals and values
- looking back and looking forward
- querying extremes
MI recognising change talk
DARN-CAT
DARN
- desire
- ability
- reasons
- need
CAT
- commitment - i will stop drinking
- activation - i am ready to …
- taking steps - i am no longer…
MI Evocative questions and reflections
Potential wish to make change (how would you like your life to look)
Their ability (what do you do well)
Reasons - why (what would be the benefit)
Necessity of making change (how important)
Ask open-ended questions more focused on CAT
Commitment questions (what do you think needs to happen next)
Use reflections as strategies for change talk
MI Importance and confidence rulers
Assess level of motivation
On a scale of 0-10 how confidence
Follow up questions:
- why 5 not 7
- why 5 not 0
- what it takes to go from 5 to 7
MI Decisional balance
Explore ambivalence to examine pros and cons of behaviours
Ask about their reasons to stay the same or change
MI Exchanging information
Respect their knowledg
Support autonomy
Ask permission to share or provide information
Make sure the patient understands by asking for their own interpretation or reaction to that info
MI exploring goals and values
Reveal discrepancies between goals and current behaviours
Often make them feel uncomfortable and prompt the need to change
MI looking back and forward
When problem began
Comparing to present
Focus on not engaging in the problematic behaviour
Hope for things to improve
MI Querying extremes
Worst things that could happen
Best things that could happen
MI Signs of readiness
- Decreased discord and sustain talk
- Decreased discuss about the problems
- Resolve: understand change is necessary
- Increased change talk: offer DARN-CAT statement
- Questions about change: ask about that it would look like
- Envisioning and experimenting: imagine pros and cons of making changes
MI Planning
- Targeted behaviour change
- Why making change
- Steps need to take place
- Who can support
- How to know if plan is working
- What can get in the way and how to address it
- What to do if plan does not work out
MI summary
Client centred
Directive method to enhance intrinsic motivation
Effective for alcohol and substance use
Components: Collaboration, compassion, evocation, acceptance
Processes: Engaging, focusing, evoking, planning
OARS: open-ended questions, affirmations, reflection, summaries
DARN-CAT: desire, ability, reasons, need - commitment, activation, taking steps
Key interventions: evocative questions and reflection, important and confidence rulers, decisional balance, exchanging info, exploring goals and values, looking back and forward, querying extremes
Self efficacy enhancement: build confidence to make and maintain behaviour change
Solution focused therapy - general
Focus on problems, origin and amelioration
Look for change already occurring and seek to build on these
Grounding: positive psych
Explore strengths and build on
Achievement of positive aims, not treating deficits
Goal attainment rather than problem solving
Client goal - better way to achieve it
Can be just do more of what already works
Building NOT teaching
NOT seeking change but deeper and more consistent grounding in who the person is
SFT - elements
- Inquiry into precession change to initiate conversation
- Use MIRACLE QUESTION to frame goal
- Search for exceptions to patterns and explore possible solutions
- Use scaling questions for status and anchor progress
- Positive feedback and homework
SFT - Inquiry into presession change
Changes occur when making and attending first appointment
Co-construct positive goal
When not identifying presession change —> narrow focus, inquire about goals for current session (what would happen to make the session useful)
Patients are often actively coping and finding solutions to keep them functioning - focus on these adaptive efforts leading to discussion of strengths and solution
SFT - miracle questions
Goals to achieve solution rather than lessening or eradicating problems
Shift the focus to future and all is going well, positive changes
Allow patient step out of current constraints
SFT - search for exceptions to problem patterns
Eg. Problem patterns at work may not show up on friendships
Explore variations in problem patterns, pointing the way to persons strengths
Helpful for those who strongly identify with their problems
Patient is the patient expert in therapy
SFT - use of scaling questions
Gauge progress and anchor solution focus
Exploring what they are doing and when they are making progress
In beginning of second session and subsequent
Positive movement: exploring what make the movement posible
Negative movement: what to do to avoid failing to the bottom end of the scale
SFT - positive feedback and homework
Reflecting strengths client can build to reach goals
Client to perceive, internalise, extend strengths
Homework: bridging time gap between sessions - NOT skills teaching as in CBT. Failure to do homework: NOT right one at the time, clear way for exploration for alternative exercises
SFT summary
NOT require diagnosis, only a clear goal
Can be for children, adolescents and families
Look for exceptions and strengths to build upon these
CBT general
Time limited 12-16 sessions
Thoughts, emotions, behaviours
Core beliefs or schemas
For depression, GAD, panic, social phobia, OCD, PTSD, schiz
First line treatment for most
Focus: teaching skills so client becomes their own therapist
Goal setting, open to feedback, completing homework
CBT Case conceptualisation
Relevant data - core belief - conditional assumptions - compensatory strategies - situations - automatic thoughts - meaning of automatic thoughts - emotions - behaviour
CBT - cognitive intervention
Identifying and evaluating thoughts causing distress
Identify - examine - evaluate - modify thoughts, assumptions, schemas
Catastrophe, back and white, tunnel vision, personalising, mind reading
Identify core belief: helpless, unlovable, worthlessness
Thought diary, worksheets, socratic questions
Start cognitive w anxiety
W depression start with behaviour first
CBT - cognitive and behaviour application
Chain analysis - vulnerability, activating events, thoughts, feelings, behaviours
Freeze a frame - describing the timelines of a specific events - helpful for suicide prevention
Understand function of behaviours
CBT - behaviour experiments
Experiment to test validity of belief or reinforce new belief
Not always possible
Goal: cognitive flexibility
For those who get something but dont yet connect w emotion
Reinforce collaboration
CBT - Psychoeducation
Education about
- the illeness
- mastering techniques to manage symptoms
Become independent in managing their own condition
Eg early symptom detection, emotional regulation, activity scheduling
Improve treatment outcomes for bipolar and schiz
CBT - Exposure therapy
Imaginal: trauma, when vino not possible
In vino: real life
Interoceptive: bodily sensation, used for panic and agoraphobia
Improve self efficacy and reduces anxiety
4 steps:
- preparation
- creation of hierarchy
- initial exposure
- repeated exposure
SUDS: subject unit distress score 1-100
Repeated daily is ideal
CBT Behavioural activation
Activity schedule
For depression
Start with this for depression before cognitive therapy
Increase sense of pleasure and mastery
Determine level of activity
Things contribute to distress
Identify plan for activities to increase PLEASURE AND MASTERY
feel motivated once starting doing activities
CBT Relaxation
Discussion of benefits and drawbacks
Purpose: provide w rapid, reliable; easy to apply means to cope and moderate anxiety
- Progressive muscle relaxation - notice tension, tense and relax different muscle groups
- Breathing restraining - hyperventilate when anxious eg panic, re-breath the air they exhaled by cupping hands over mouth, or lunch bag - taught in session, practice for homework-
Slow and calm breathing: diaphragmatic breathing, rhythmic breathing
^^^ the above 2 NOT CBT specific
CBT Sessions
- mood checking and agenda setting
- review homework
- discuss agenda topics and teaching skills
- setting homework
- summary
- feedback
Treatment outline:
Depression: assessment, psycho ed, behavioural activation, cog restructuring, core belief work, symptom improvement, termination
Anxiety: assessment, psycho ed, emotional regulation, cognitive strategies, exposure work, core belief, symptoms improvement, termination
CBT summary
Time limited and brief
First line for many
Cog, behaviour, education
Guided discovery
Collaboration
Structured
Homework, skills building
Though log, common thinking errors, behavioural experiment, modification, underlying belief
Level of evidence
- Meta analysis OR systematic review of level 2 studies
- Test accuracy w independent, blinded comparison, among consecutive persons w a defined clinical presentation
3.1. Pseudorandomised controlled trial (alternate allocation or other method)
3.2. Comparative w concurrent controls: non randomised, experimental, cohort, case control, interrupted time series
3.3: comparative study without concurrent controls: history control; 2 or more single arm, interrupted time series
- Case series
Psychodynamic - general
Unconscious - subconscious
Goal: improve personal connection w others
Founded: freud psychoanalysis
Client - therapist is key factor
More time limited and outcomes focused than tradition
Depression, anxiety, personality
Candidate: capacity for self reflection, looking to obtain insight
Brief therapy: 25 sessions
Psychodynamic vs psychoanalysis
Both: intrapsychic prosesses, unconscious processing more than others
Dynamic: shorter (frequency and number of sessions)
Psychodynamic characteristics
Recognising, acknowledging, understanding, expressing, overcoming negative and contradictory feelings and repressed emotions
Improve interpersonal experiences and relationships
Understand how repressed emotions from past affect current decision, behaviour, relationships
Therapist active role but NOT directive
Therapist role: look for avoidance, evasive behaviours, to help client process subconscious desired, appraisal, and fears
Goal: uncover and process internal conflicts
Client to express full range of emotion, allow therapist to analyse patterns and interpret underlying maladaptive thoughts and conflicts
Therapist look for avoidance strategies and contradictory expressions
Challenge internal conflicts thoughts: goal setting, reality testing, confrontation, empathetic validation
Sound alliance is crutial
not only relive symptoms but foster positive presence of psych capacities and resources
Psychodynamic- triangles of conflicts and person
Dysfunctional defence mechanism (D)
Anxiety and Inhibitory affects (A)
Unacceptable feelings and impulses (F)
Parents and past person (P)
Current people (C)
Transference w therapist (T)
Psychodynamic- aims
Resolve presenting problems by targeting specific elements in problem formulation
Defence restructuring: recognise defence and motivate to give up defence
Affect restructuring:
- affect experiencing: experience and accept forbidden adaptive feelings without anxiety
- affect expression: seek socially acceptable ways to express forbidden feelings
Self-other restructuring: develop more tolerant attitude towards self and - more accurate and compassionate view of others - modifying internalised models of self, others, relationships learned during childhood
Psychodynamic- transference
Transference: client respond to T in the way they respond to P
Resistance: using various D to regulate A associated w threat of uncovering F - therapist respond in supportive rather than a punitive way
Therapist: psychological reaction to client resistance - source of info about how their D impacts others
Countertransference: immediate, intense, reactions from T to client behaviours
Can be therapist own sensitivities to particular issues
Psychodynamic- summary
Termination: problems resolved, grief associated w ending therapy is addressed
Triagles of conflicts
Recognise and relinquish dysfunctional defences and replace w more adaptive ones
Desensitise to experience if forbidden feelings and impulses to help develop healthy way to express these
Help develop more positive self-image and capacity to engage in positive relationships
Humanistic - assumptions
- each person has unique way of perceiving and understanding the world
- take subjective than objective view (what is it like to be this person)
- reject objective scientific method
- endorse idea that people have free will and capable of choosing their own actions
- all people have tendency to grow and fulfil their potential
Humanistic - explaining behaviours
Rogers
Person conscious and own ideas
People could fulfil their grow if they have positive self regard, only happen if they have unconditional positive regards to others
Feel valued and respected without reservation from others
Problems: they think they only be loved if they meet certain conditions - leading to incongruence between real self and ideal self
Closing the gaps with unhelpful way, eg chasing achievements that dont make them feel content
Maslow
People have variety of needs in hierarchy
Satisfied all needs - self actualised
Prolong period of needs not satisfied - fixation
Humanistic- studying behaviour
Methods to understand people subjectively
Avoid methods studying people objectively, including quantitative approach
Prefer: qualitative and unstructured interview
Analyse materials eg diaries, letters, biographies
Humanistic- evaluation
Lack of objectivity: criticism
Facilitate growth by building strengths and fostering sense of agency to achieve goal and fulfil potential
Client centred
Therapeutic relationship is key
Narrative therapy
Perceptions and self concept are organised through personal stories - working with these stories in therapy
Therapist: help client identify which aspects they focus/ omit - identify opportunities for growth and healing
Help replace dominant, maladaptive narratives with healthier alternatives
Encouraged to separate themselves from the problem
Useful for indigenous aus - yarning
Opening up to address sensitive issues such as addiction, DV, loss and grief
2 steps:
- deconstructing dominant narrative (1)
- reconstructing preferred, more freeing narrative (2)
(1) re-examine from a new angle
Separate person identity and background
Through externalising conversations
(2) notice aspects contradicting earlier narrative
Unique moments or exceptions
Use direct questions - what does this suggest to you
Client evaluate impact of the story
Narrative therapy - training exercise
Internalised:
- i’m a worrier
- he is unmotivated
Externalised
- what does the worry say
- how does it affect his motivations
Family system therapy
Improve couple relationships and psych conditions in children and teens
Fundamental role of parents in children development and value of including the whole system
Couple intervention
Family communication exercise
How to create functional family relationships
What happens to one member happens to eveyone
Use for:
- substance use
- depression
- anxiety
- bipolar
- personality
- eating disorders
- coping w physical disabilities
Family therapy - key principles (8)
- differentiation of self (sense of individual rather than relying on others in the family)
- the triangle: relationships between 3 people impact others
- nuclear family emotional process: emotional distance, relational patterns
- family projection process: parents display feelings onto children / then children to others
- multi generational transmission process: small differences in differentiation between children and parents leading to larger difference among extended family members
- sibling position: birth order affect dynamic
- emotional cutoff: conflict w no resolution - sever relationships
- emotional processes in society: broader social and cultural forces influence family relationships
Pharmacodynamics
Neurotransmitter: chemicals communicating info throughout brain and body
How the transmission if info is impacted when a psychotropic is taken
What a drug does to the body? Effects of the drugs?
Pharmacokinetics
Psychotropic passing through the system
- absorption: transfer to the blood stream
- distribution: crossing into the central nervous system
- metabolism: in liver, changing drug structure)
- elimination: removal of agent to urination and respiration
What does a body do to a drug - fate of drug in the body
Age, physiological function, gender, disease, nutrition
Half life
Average time to eliminate 1/2 if the drug concentration from one system
Therapeutic index
Quantitative measure safety of drugs
Therapeutic dose: concentration that give desired responses
Toxic dose: concentration causing mild to severe side effects
Therapeutic index: ratio of toxic to therapeutic dose
The amount of agent causing effect to the mount of agent causing toxicity
Higher therapeutic index = more desirable as risk is less
Range of dose at which medications is effective without unacceptable adverse side effects
Potentiation and synergism
Potentiation: one drug enhance effect of second drug
Drug can also be antagonistic and counter the other’s effects
Placebo response:
Shown therapeutic response as if actual drug is present
Drugs and central nervous system
Aminobutyric acid GABA
Acetylcholine: memory, learning, attention
Epinephrine (adrenaline): regulate fight or flight response - anxiety
Norepinephrine: wakefulness and alertness
Dopamine: behavioural regulation, movement, learning, mood, attention - schiz
Receptors are activated by amphetamines and cocaine
Drugs for depression
Antidepressants
Physiological symptoms: sleep, appetite, fatigue, inflammation, sex drive, restlessness, concentration, forgetful.
For those poor psych candidates eg low intelligence, refusing therapy
2 primary groups:
- typical: fluoxetine, fluvoxamine
- MAO inhibitors: phenelzine, tranylcypromine
Clinical picture: anxiety, agitation, obsessional, rumination, irritability, aggression - SSRI BEST CHOICE
Apathy, low energy, inability to feel pleasure, low motivation - DOPAMINE OR NORADRENERGIC preferred
Start at low dose and gradually increase
4-5 weeks of treatment - increase dose if no positive response
Drug for depression - treating phases (3)
Acute treatment: first dose and extends till asymptomatic
Continuation treatment: avoid relapse, continue treatment for at least 6 more months
Maintenance treatment: relapse prevention, continue lifelong treatment for best outcome
Drugs do not act immediately
Take 2-4 weeks for symptoms to be improved
Manage expectations w clients
Drugs for depression side effects
Increase anxiety, restlessness, insomnia during first week or two
SSRI and SNRI prescribed for depression, low incidence of side effects
Late onset side effects: sexual dysfunction, decreased apathy, weight gain,
Drugs for depression- errors
Under dosing
Poor compliance
Misdiagnosis: bad for bipolar
Co-morbid substance abuse: alcohol use
Longterm use if benzodiazepines for depression
Premature discontinuation
Rapid discontinuation (getting off too quickly)
Drugs for depression - communication to patients
Clinical actions may take 2-4 weeks
Not happy pills, no do erase feelings of sadness, emptiness
Improve physical symptoms only: better sleep, less fatigue, emotional control
They may say “i’m not better”
May be side effects
NOT ADDICTIVE
Avoid alcohol
Never discontinue cold turkey - withdrawal symptoms
Include exercise and reduction of substance for sleep
Depression if first line med do not lead to remission?
- misdiagnosis
- missing common unsuspected medical co-morbidities (obstruct sleep apnea, restless legs syndrome, sleep disturbance)
- 15-20% present w atypical symptoms eg weight gain, hypersomnia, carb craving
Drugs for depression - drug effects w others
MAO Inhibitors - never use w SSRI
Tricylic antidepressant- may increase TCA level
lithium- SSRI may increase lithium level
Carbamazepine: SSRI may increase this
St John wort: may be dangerous
5-HTP with SSRI: serotonin syndrome and can be dangerous
Drugs for bipolar
Reduce frequency of episodes
Primary: Lithium- decrease chance of suicide, prevent relapse for mania than depression
- manic episode: anti manic medications or antipsychotic medication (olanzapine) - for behaviour control
Manic episode:
- extreme: antipsychotic, benzo
- classic: lithium, divalproex
- mixed mania: divalproex
- rapid cycling: lamotrigine or divalproex
Depressive episode: mood stablizer eg lamotrigine, olanzapine, OFC, lithium
Combination of medication: lithium -‘d quetiapine
Lithium - bipolar
Therapeutic range close to toxic range
Need to gradually increase dose + close monitoring blood level
One mood stablised - reduce dose for maintenance
Side effects: nausea, diarrhea, vomitting, hand tremor, sedation, muscular weakness, weight gain, dry mouth
Toxicity: slurred speech, severe vomiting, tremor, hypotension, seizures, shock, coma, even death
Drugs for bipolar - communicate to client
Not treating emotional problems
Continue medication even once episode is resolved
Regular blood monitoring required for lithium
NOT ADDICTIVE
lifestyle management: regular sleep, avoid shift work, sunlight exposure
Avoid alcohol and drugs, avoid substances interfering sleep eg caffein
Limit travel across timezone
Drugs for anxiety
GAD - SSRI, buspirone
Stress related anxiety: tranquillizers help reduce restlessness, insomnia for situational stress, diazepam, lorazepam
Antianxiety only be used for 1-4 weeks
If just one in a series of chronic life crisis: NO benzodiazepines
Panic: 4+ attacks in a month - medication for panic disorder, alprazolam, lorazepam, MAO inhibitors, antidepressants
Social phobia: not treated w med, beta-blockers, MAO inhibitors, venlafaxine, SSRI, may be helpful
Medical illness causing anxiety: treat the illness
Anxiety as part of mental conditions: treat the condition
Drugs for panic disorder
2 phases:
- eliminate or reduce frequency and intensity of panic attacks w anti panic drugs (3 groups - see below)
- once panic attacks are controlled, gradually exposure to feared situations
- High potency benzodiazepines:
- effective, quick
- require large dose, sedation is common problem - Antidepressants: tricylics, SSRI (selective serotonin reuptake inhibitors), venlafaxine, mirtazapin
- effective, not addictive
- side effects, delayed onset - MAO inhibitors
- effective, not addictive
- delayed onset, restrictions involved
Drugs for anxiety - errors
Substance abuse
Cold turkey (discontinuation or rapid taper of benzodiazepines) - withdrawal, 1-3 taper advised
Misdiagnosis: failure to recognise depression or psychotic illness, benzodiazepines makes depression worse
Sedated from benzodiazepines
Cognitive impairment for older clients using benzodiazepines
Discontinuation of caffein
Drugs for anxiety - communicate w patient
Allow 2-6 weeks
Daily doses required
Combine w therapy
Tranquillizers for short term use only
Do not discontinue
No alcohol
Drugs for psychotic - schiz symptoms (4)
Positive (high)
- delusions and impaired thinking
- hallucination
- confusion and impaired judgement
- anxiety, agitation, emotional dyscontrol
Negative (depressed)
- flat, blunnted affect
- poverty of thoughts
- emptiness
- retardation, inactivity
- blunting of perception
Disorganisation
- incoherent speech
- bizarre behaviour
- extreme confusion
Characterological traits
- social isolation, sense of alienation
- low self esteem
- social skills deficits
Antipsychotic medications
Referred to a psychiatrist
Start w early sighs of psychosis appear
Early intervention prevent more florid psychotic episodes occurring
Do little to affect characterlogical traits or negative symptoms
All are equally effective in reducing positive symptoms
Choice is about side effects eg weight gain, metabolic effects, sedation effects, restlessness, blurry vision, dry mouth
Start at low dose
Decrease in arousal, emotional dyscontrol, agitation
Some symptoms can take several weeks to response eg hallucinations, distorted thinking
Reduce and maintain for one year
Treating for 2-3 years before medication free trial
Antipsychotic - talk to client
Side effects
Non compliance - more suffering
Schiz is prone to relapse, keep taking medications even when feeling fine
Length of treatment: one year +
Not additive
Avoid high temperatures, sunlight, some medications have photosensitivity side effects
Avoid amphetamines, cocaine, l-dopa
Drugs for OCD
Antidepressant and CBT
4-8 weeks
Drugs for borderline
Psychotropic for particular symptoms
NOT the personality disorder
Impulse control: SSRI, atypical antipsychotic
Schiz (peculiar thinking): antipsychotic, olanzapines
Sensitivity to rejection: atypical antipsychotic
Emotional instability: lithium, divalproex, atypical antipsychotic
Drugs for ADHD
Prolonged medication treatment
Risk of being abused by predisposed to chemical dependency
Stimulants:
- ritalin
- metadate
- adderall
Drugs for PTSD
Treatment of choice: psycho therapy
Medications for symptoms only: panic, depression)
Treating w benzodiazepines is NOT effective
Drugs for sleep disorders
Obstructive sleep apnoea: CPAP (airway pressure)
Insomnia: shortterm benzodiazepines (temaze, serepax)
Dependence within a few weeks of use
Take in sleep phase, sedation effect
Nightmare may occur
Drugs for substance dependence
Acamprosate (campral) - alcohol dependence, 3 times per day, no side effects, modest efficacy
Naltrexone (revia)- opioids
Methadone - opioids
Marijuana
Smoke
Rapid absorption to the brain
Effect within 5-10 mins
Peak at 30 mins
Diminish at 90 mins to a few hours
High dose causes: delirium w confusion, agitation, loss of coordination, hallucinations
Acute anxiety or panic
Long term effects: bronchitis, lung cancer
Main effects: euphoria; disinhibition, increased appetite
Withdrawal: insomnia, hyperactivity, decreased appetite
Heroin, opioids
Narcotics
Central nervous depressants
Slow respiration, increased body temperature, slurred speech and impaired memory,
Overdose: convulsions, coma, death
Analgesics: Stop brain from receiving pain signals
Addictive, high rate of abuse
State of sedation
Withdrawal: anxiety, dysphoria, muscle aches, irritability, vomiting, diarrhea, restlessness, sick and painful
Cocaine
Stimulant
Frightening paranoia
Fast acting stimulant w short acting effects
Surge dopamine
Difficulties sleeping; apathetic, irritable, agitated, depressed
Methampetamine
Excess activity, appetite reduction, euphoria, alertness, increased libido
Anxiety, paranoid, psychosis, violence, tremors
Withdrawal: anxiety, sleep disturbance, chronic fatigue, irritability, depression and craving
Overdose: Seizures, agitation
Last 2-4 hours
Alcohol
Mostly used for depression
Drowsy, sedated, decreased inhibition
Works like a numbing agent
Liver, digestive, nutrition problem
Wernicke-koraakoffs syndrome: eye movement disturbance, lack of muscle control, coordination, confusion, short term memory problems - can be treated w thiamine. - if not psychosis may develop and can be permanent
Overdose: coma, death, nausea, vomiting, cold clammy skin
High level: agitation, irritability, anxiety, insomnia, trermors
Dangerous withdrawal: psychosis, seizures, within 2-3 days not drinking
Inhalants
Inhale shoe polish, paint thinner, certain types of glue, petrol fumes
Depress the central nervous system
Mild intoxication to unconsciousness
Last for a few minutes to few hours
Lung disease and brain damage
Overdose: death, coma, seizures
Caffeine
Reduce fatigue, increases alertness, decrease appetite, raise heart raise
Large dose cause headaches, irritability, stomach upset
Dependent of caffeine, feel sleepy, lethargic without
Small quantities is safe, large dose can be dangerous
Unaware, amount of caffeine they are ingesting
Herbal supplements
St johns wort is s herbal condition used to treat nervous conditions
Popular herbal remedy for mild depression
Dry mouth, dizziness, photosensitivity, gastro, fatigue, as specific common side effects
Safety in pregnancy is not yet clear
Encouraged to discuss, any supplements w doctor.
Efficacy for treating mild depression
Unclear whether it’s just simple placebo
Medications summary
ADHD: methylpheniDATE
Mood stablizer, bipolar: lithium
Anti-psychotic (also for aggression in ASD): risperidone
Anti-psychotic: clozapine
Anti-psychotic: olanzapine
- dole, -done, -zole
SSRI, antidepressants:
- (zoloft) sertraline
- (celexa) citalopram
- (lowan, prozac): fluoxetine
- (lexapro): escitalopram
Benzodiazepines:
- (xanax) acute anxiety, panic: alprazolam
- (valium) acute stress related anxiety: diazepam
- (klonopin) acute anxiety/ panic: clonazepam
- (alprazolam) anxiety/ panic
Reliability
Consistency of measure:
- test-retest: repeat and get similar result
- alternate forms: scores on both test highly correlated
- internal consistency: how well items relate to one another (cronbach)
- interrater consistency: observation data from multiple sources (eg 2 clinicians) - measure how much raters agree with what they are observing
Validity
Test accurately measures what it is supposed to
Construct: validity of measure being used - does it assess what it’s supposed to
Criterion-related: how accurately a test measure the outcome it was designed to measure
Content: instrument contains construct-relevant material and does not contain irrelevant material, scores are not influenced by irrelevant materials
Group designs - randomised controlled trials (true experiments)
Gold standard
Participants are randomly assigned to groups
IV is manipulated differently across groups
Keep variables outside IVs constant
Quasi experiments: non ramdom assignment (as randomised is not legal or ethical)
Between subject design: comparing effects of treatment between subjects or groups - any different effects on DV
Pretest-posttest control group: popular for clinical, 2 groups, random assignment, one group receives treatment, one does not. See changes in scores before and after treatment
Within subject design: comparing effect of treatment within one individual
Longitudial: single groups, over time, vulnerable to many factors eg maturation, attrition, measurement effects
Meta analysis
Use results from previous studies
Leading method
Identifying the topic
Collects studies
Obtain average effects
Calculate weighted average effects (size of each study)
Effectiveness vs efficacy studies
Efficacy:
- cause and effect relationships between IV and DV
- require special attention to internal validity (experimental control)
- does x work
Effectiveness:
- how well x work in real world settings
- generalisability or external validity of findings
- impacts of x on community
- apply to real clients, therapists
Research in clinical practice
Most are efficacy studies
External over internal validity
Treatment outcomes on individuals than in comparison w control group
2 parts:
- apply psych science to evaluate own practice
- use science to inform how we choose to practice
Counselling skills
- cultural responsiveness in providing interventions to diverse groups (understand most research done on white US)
- establishing therapeutic relationships and therapeutic alliance
- listening skills (show through various ways)
- responding skills: supportive, empathetic, reflection, questioning, summarising
- listening response: clarification, paraphrasing, reflection: reflect their feelings, summarising
Problem resolution and change based strategies
5 stages
- Empathetic relationships
- Explore story and strengths
- Setting goals mutually
- Working and exploring alternatives and conflicts, actions involving applying changes to life
- Generalisation of learning and termination
5 stage of change
Pre-contemplation: unaware
Contemplation: aware, not able to
Preparation: decision maded
Action: engage
Maintenance: new behaviour for 6 months
Monitoring progress and termination
Observation and use of measurements
Termination:
- safeguards wellbeing
- plan at the beginning
- when goals are met
- not abrupt
- consolidate gains and troubleshoot likely future obstacles
Premature termination cause: unmet expectations
Counselling characteristics
Skills:
- congruent (genuine)
- empathic
- non-judgemental
- unconditional positive regards
- attention
- collaborative relationship
- respect
- use counselling skills purposely
Problems in counselling
Rupture: misunderstanding or conflict between therapist and client
Re-enactment: same type of problem is played out in therapy sessions
