Psychotherapy Flashcards
What is interpretation in psychodynamic therapy?
Refers to the expression of therapist’s understanding of the meaning of feelings,
attitudes, defense mechanisms and behaviours currently exhibited during therapy. Interpretation
is usually based on psychoanalytical theory practiced by the therapist. Interpretation made by a
therapist sheds light on an unconscious process in the patient, therefore making it accessible to
the conscious mind.
What is transference?
The feelings, thoughts and attitudes given to a person in the present (such as the
therapist), that do not befit that person but actually originate from a person or figure in the
patient’s past (such as a parent).
What is countertransference?
The therapist’s spontaneous feelings and emotions that are evoked when
s/he ‘tunes in’ to the patient’s unconscious communication, including the patient’s transference.
Analysing counter-transference can provide insight into a patient’s psychic state in the same
sense as analysing transference.
What is acting out?
Performing an action to express unconscious emotional conflicts.
While
acting out, the unconscious impulse is discharged by means of an action instead of verbalization.
What is working through in psychodynamic therapy?
A process of unlearning prior misconceptions and
learning new constructions.
Immature defence mechanisms
Acting out
Regression
Denial
Psychotic defence mechanisms
Splitting
Idealisation/denigration
Projection
Projective identification
Neurotic defence mechanism
Repression Intellectualisation Rationalisation Reaction formation Displacement Magical thinking
Mature defence mechanisms
Humour
Altruism
Sublimation
CI to psychodynamic therapy
Poor impulse control
Poor frustration tolerance
Low motivation.
Antisocial personality disorder
Absence of psychological mindedness (ability to scrutinize and verbalize one’s own cognitive
processes)
Being in the midst of a major life crisis.
Poor ego strength (capacity to shuffle oneself appropriately between two different ego states e.g.,
being a passive and dependent patient vs. being autonomous and plan one’s routine life outside
the therapy)
Severe active psychosis
Poor ability to form and sustain relationships
Indications for supportive psychotherapy
Helpful for periods of transition and adaptation, when a
deeper working through particular problems is not required
Methods in brief psychodynamic therapy
Goal setting and explicit identification of the anxiety and defenses to be tackled.
Focus choosing: Identification of currently active problem (here and now – core conflictual
relationship themes that represent cyclical maladaptive patterns are focused). Explore
symptom precipitants and associated early trauma and avoidance.
Active interpretation: Therapist may guide therapy by use of interpretation at an earlier point
than in more prolonged methods.
Creating heightened emotional contexts conducive to change
Predictors of good outcomes in brief, psychodynamic therapy
Circumscribed problem Strong motivation Able to express feeling at assessment Psychological-mindedness At least one good relationship Evidence of achievement Not actively suicidal, chronically obsessional or phobic Not grossly destructive or self-destructive; not actively abusing illicit drugs
Primary aim of supportive psychotherapy
To support reality testing
Provide ego support
Reestablish usual level of functioning
When to use supportive psychotherapy
in otherwise healthy patients with overwhelming ongoing crises and those
with ego deficits. Also useful in those who are not psychologically motivated to ‘explore’
themselves. This is not time limited and the therapist must be predictable available in times of
need. Problem solving, advice, reinforcement and reassurance are the main tools.
Key idea of general systems theory in family therapy
A system is a set of interconnected components that form a whole; The components
show properties of the whole, rather than of individual components; Cycles of feedback between
different components within the system continuously create and re-create a basis for interaction.
Types of family therapy
Behavioural Psychoeducational Strategic Family systems approach Structural Dynamic
What is aim and theory of dynamic family therapy
•Theme: To bring to light forces at play that influence the way a family functions. Emphasizes
individual maturation in the context of the family system.
•Theory: There are unconscious processes which, when noticed and worked through, can bring
relief to the family’s conflictual experiences
Methods of dynamic family therapy
Makes interpretations, noticing the formation of alliances, dyads and triads between
members. Therapists seek to establish an intimate bond with each family member. Family
sculpting refers to family members physically arranging themselves in a scene depicting
individual view of relationships.
What is aim and theory of structural family therapy
•Theme: Challenges the patterns of behaviours or interactions that disrupt a family structure.
•Theory: A well-functioning family has a structure: clear hierarchies, boundaries between
generations, and well-defined rules. When these are disrupted, problems occur.
Methods of structural family therapy
The therapist challenges the interactions between the generations. Both individual
and family sessions used.
What is aim and theory of family systems approach to family therapy
•Theme: Emphasizes one’s ability to retain individual self in the face of familial tension.
•Theory: An emotional triangle is a three-party system where closeness of two members (in
either positive or negative sense) tends to exclude a third. This hot triangle leads to symptom
formation
Methods of family systems approach of family therapy
The degree of enmeshment is analysed. The therapist maintains minimal emotional
contact with family members. Bowen also found a tool to analyse history of families across
generations – called the genogram.
What is the aim and theory of strategic approach of family therapy
•Theme: Aims to find the positives in a system and builds on them
•Theory:Problems within families can be maintained by over-emphasising them, so that they end up being
maintained rather than resolved
Method of strategic approach to family therapy
•Activity:Positive reframing: finding the positive in negatively-labelled interactions
•Utilizes the domino effect: if one problem is properly addressed, it leads to reduction or resolution of other
problems
What is the aim and theory of psychoeducational approach of family therapy
•Theme: The objective is to enhance family support and reduce stress
•Theory: There is a risk of relapse when family interactions are overinvolved, emotionally charged and
critical. The course of mental illness, such as schizophrenia, will be affected by these stress levels and the
counterbalanced by support available.
Method of psychoeducational approach to family therapy
Focuses on helping families to understand factors that affect stress levels, helps facilitate
communication and encourages problem-solving strategies.
What is the aim and theory of behavioural approach of family therapy
•Theme: The aim is to closely observe and evaluate behaviours in the family so as to identify problems and
make specific interventions.
•Theory: Behaviour is essentially maintained in a more or less linear model. Symptoms are viewed as learned
responses that reinforce dysfunctional patterns of relating.
Method of behavioural approach to family therapy
•Activity: Treatment is symptom-focussed and time-limited. The therapist’s personality is not important, but
therapist action is.
What is the Milan systemic approach to family therapy?
Gives great emphasis on circular and reflexive
questioning. In a circular fashion each family member is asked to comment and reflect on each
other’s response.
What is paradoxical therapy?
Therapist makes the patient intentionally engage in the unwanted behavior (called the paradoxical injunction) e.g., avoid a phobic object or perform a compulsive ritual. This counterintuitive approach can provide new insights for some patients.
What is operant conditioning?
Changing behaviour by use of reinforcement
What is systematic desensitization based on?
The behavioral principle of
counterconditioning (i.e. gradual approach of feared situation in a psychophysiological
state that inhibits anxiety leads to reduction of anxiety response.) and reciprocal
inhibition (i.e. when anxiety and a relaxed state are co-existent, then anxiety reduces).
Steps in systematic desensitization
- Relaxation Training
- Constructing a Hierarchy of Anxieties
- Desensitization of the stimulus
What happens in systematic desensitization
The patient is exposed to a graded hierarchy of anxiety-provoking situations in
stepwise fashion.
Explain concept of relaxation in systematic desensitization
Relaxation produces physiological effects opposite to those of anxiety. In
progressive relaxation patients relax muscle groups in a fixed order
starting from small muscle groups working upwards
What happens in graded exposure therapy
relaxation training is not involved, and treatment is
carried out in a real-life context though in a hierarchical fashion.
What happens in autogenic training
a method of self-suggestion whereby the subject directs
his/her attention to specific bodily areas whilst carrying out a relaxation exercise
What is applied tension?
a technique that is the opposite of relaxation is used to
counteract the fainting response (for example in injection phobias)
What is flooding?
In flooding based therapy, real life (in vivo) exposure happens without any
hierarchy: the anxiety is not avoided but tackled head-on! Escaping from an anxiety-
provoking experience, in fact, reinforces the anxiety through avoidance conditioning; in
flooding this conditioning is targeted.
What is success in flooding based on?
The success of flooding depends on exposing patients for a reasonable duration until
mastery and calm composure are gained. Premature withdrawal will reinforce the
avoidance.
What is the name of imaginal flooding?
Implosion
When is flooding CI?
Poor stress tolerance
Cardiac morbidity that may cause ischaemia
Describe massed negative practice
frequently used in tic disorder, when the patient is asked to
deliberately perform the tic movement for specified periods of time, interspersed with
brief periods of rest.
What conditions is habit reversal training used in
OCD
Tic Disorder
Describe habit reversal training
Awareness training: becoming aware of what stimuli/situations provoke the behaviour
Competing response training: teaching responses that counteract the behaviour (e.g., in
forearm flexion, the patient practices forearm extension)
Contingency management: positive reinforcement for the desirable behaviour
Relaxation training
Generalisation training: once one component has been mastered; this is generalised to
other problem behaviours.
What is behaviour rehearsal?
Real-life problems are acted out under a therapists observation and direction
Theory of biofeedback?
Involuntary autonomic nervous system can be conditioned by the use of
appropriate feedback
Which autonomic functions can be conditioned
Autonomic functions conditioned include skin temperature, electrical conductivity,
muscle tension, blood pressure, respiratory rate and heart rate.
Which conditions can be treated through biofeedback
migraines, asthma, hypertension and angina
What is social skills training
employs a multitude of learning principles to aid in
recovery and rehabilitation of long-term serious mental illnesses such as schizophrenia.
Models of social skills training
- The basic model: here complex social repertoires are broken down into simpler steps,
subjected to corrective learning, practiced through role playing and applied in natural
settings. - The social problem-solving model: This focuses on improving impairments in information
processing that are assumed to be the cause of social skills deficits. The model targets
domains needing changes including medication and symptom management, recreation,
basic conversation, and self-care. - The cognitive remediation model: Here the corrective learning process begins by targeting
more fundamental cognitive impairments, like attention or planning. The assumption
is that if the underlying cognitive impairment can be improved, this learning will be
transferred to support more complex cognitive processes, and the traditional social
skills models can be better learned and generalized in the community.
Principle of behavioural analysis
Each behaviour serves a purpose for a person. Identifying such function (may be positive
or negative reinforcement) is important to manipulate behaviour through therapy. This
forms the principle of functional assessment.
What does behavioural analysis consist of
1) Identifying Motivating Operations (why is it happening)
2) Identifying Antecedents/Triggers for the behaviour (what triggers it to happen)
3) Identifying the Behaviour that has been operationalized (what exactly happens)
4) Identifying the Consequences of the behaviour, which reinforces it (what keeps it
happening)
What is a behavioural treatment plan?
Conducting a Functional Analysis can assist in making a
behavioural treatment plan. Identify clearly the problems/symptoms, set short-term and
long-term goals and objectives, define specific interventions/actions, and decide how
outcomes will be measured (e.g., Use of a chart to mark symptom reduction, or to measure
change in incidences of aggressive behaviour).
How are behavioural interventions measured in behavioural analysis?
Repeatability refers to the frequency of the behaviour.
Temporal extent refers to the duration of each instance of behaviour.
Temporal locus refers to the time point at which each instance of behaviour occurs.
Response latency is the measured time interval (reaction time) between the onset of a
stimulus and the initiation of the response.
Inter-response time is the amount of time between two consecutive responses.
Describe negative automatic thoughts or cognitive distortions
cognitions that automatically
arise in certain situations or as a reflex
response to certain behaviours
What are conditional assumptions?
Rules or
guidelines for life – they usually start with
the phrase ‘I must’ or ‘I should’
What are core beliefs or schemes
Ones appraisal of oneself
Name the maladaptive cognitive assumptions
Minimisation and magnification Over-generalizing Selective abstraction Personalization Arbitrary inference Dichotomous thinking Catastrophization
Cognitive assumptions in panic disorder
Catastrophic misinterpretation of physiological experiences
Cognitive assumptions in OCD
- Thoughts are as powerful as actions (thought omnipotence)
- Alternative or substitute action can undo or compensate for another
thought or action.
What maintains cognitive distortions?
Situational avoidance
In-situation safety behaviours
Attentional deployment
Rumination
What are in-situation safety behaviours?
Variety of
subtle behaviours/internal mental processes that most
patients engage in while in a fearful situation. These are
actually intended to prevent feared outcome. E.g.,
bowing the head down and gently leaning leftwards
when having a panic, with a hope to increase heart’s
circulation. This makes one believe erroneously that
this behaviour is the reason why one survived the
‘attack’. Commonly, patients engage in a large number
of different safety behaviours at any time during a
crisis.
Techniques employed in CBT
Guided discovery
Questioning identified beliefs
Testing predictions
Stages of guided discovery
Stage 1: Asking informal questions Delineate patient’s concerns
Stage 2: Listening To be clear about exact issues
Stage 3: Summarising To demonstrate understanding and to revise
Stage 4: Synthesizing / analytical
questions
‘How does all the information discussed fit
with your idea that you are a failure?’
What is guided discovery?
Refers to a style of the interview where sensitive questioning allows
patients to reach new interpretations/ reframe their cognitions independently; therapist
guides self-discovery and does not prescribe the solution.
CBT approaches for anxiety
Behavioural experiments
Imagery modification
Cognitive restructuring
Dropping safety-seeking behaviours
Describe behavioural experimination
follow construction of hypothesis about symptoms e.g.,, a
hypothesis that ‘when one has a panic attack he will not get suffocated even if he is not
hyperventilating or holding tight to his chest’ is tested through homework by the patient
conducting an experiment of not holding tight and not hyperventilating and reporting the
event in next session. This helps to:
1. Establish that a feared catastrophe will not happen;
2. Discover the importance of maintaining factors;
3. Discover the importance of negative thinking;
4. Find out whether an alternative strategy will be of any value; and
5. Generate evidence for a non-disease-based explanation
Describe dropping safety seeking behaviours
Patients can test out the effects of these behaviors for
themselves by conducting an alternating treatment experiment. This experiment involves,
first, increasing the target behavior for a day—such as bodily checking and information
seeking—and, second, monitoring anxiety, bodily symptoms, and strength of belief at
regular intervals. On the next day, the patient has to ban completely carrying out the
target behaviour, but once again, anxiety, symptoms, and strength of belief are monitored
at intervals. The resulting data is reviewed and graphed at the next session.
Techniques in CBT for OCD
Thought stopping
Thought postponement
Exposure and response prevention
Describe thought stopping
Patient shouts stop or applies an aversive stimulus such as pressing nails to counteract obsessional preoccupation
Describe thought postponement
Postponing the thought until specified time and not delaying it until then to gain control
Describe ERP in OCD
refers to a paradigm similar to systematic
desensitization where the hierarchy of obsession provoking situations is created and
exposed to while preventing any compulsions or responses being carried out.
Techniques in CBT for hypochondriasis
Self-monitoring through thoughts diary
Inverted pyramid technique
Selective physical attention experiments
What is the inverted pyramid technique
The
patient is asked to estimate the current number of people with a particular symptom (i.e.,
those who have it today), the number for whom it persists, the number who consult their
doctors, the number who are told they need tests, the number who are told the problem is
serious, and the number who are not successfully treated..
Helpful to address overperception of risk
Describe selective physical attention experiments
Patients are asked to focus on a specific body
part for several minutes (one that is not a current cause for health anxiety); after which,
they are asked to describe any bodily sensations they notice. Most patients will detect
sensations that they were unaware of before the experiment—for example, tightness in
throat, tingling in feet. This exercise is helpful as a demonstration of the effects of
symptom monitoring and bodily checking.
CBT techniques for psychosis
Coping strategy enhancement
Relapse indicator identification and control
Symptom relief; weigh evidence that contradicts a delusion
Therapeutic alliance – not colluding with delusions but validation.
Improving medication adherence.
Providing alternate explanations to unusual experiences e.g., normalisation.
Decreasing the impact of positive symptoms e.g., addressing the omnipotence of
voice.
Graded reality testing using peripheral questioning and inference chaining.
Describe coping strategies for psychosis in CBT
Affective - relaxation, sleep
Behavioural - being active, drinking alcohol
Cognitive - distraction, challenging voices, switching attention away from voices
What are group processes in group therapy?
The central premise is that the behaviour and dynamics of the whole (the
group) cannot be derived solely from its constituting parts (the individuals within the group).
Once formed, the group will develop its own way of existing/it’s own culture, with particular
norms, roles, relations and goals.
What are group alliances in group therapy?
refers to the quality of the relationship that develops between each individual
member and the therapist.
What is positive identification in group therapy?
refers to an unconscious group mechanism in which a person incorporates the
characteristics and the qualities of the group.
Types of group therapy
- Highly specific target oriented groups include structured groups for drug use or alcohol
use, activity groups like occupational therapy groups, etc. These groups have a high level
of leader input. - Psychodrama, music therapy, systems-centred groups are some less specific therapies but
are highly directed by the leader or therapist. - Problem-solving therapy and psychoeducational groups are highly specific but have a low
level of therapist activity. - Support groups, art therapy, interpersonal therapy and groups like Tavistock model
analytic groups have a low level of leader activity and have low specificity with respect to
treatment goals.
What are basic assumptions in psychodynamic group therapy
Described that when a group gets derailed from its task, it goes into one of three basic
states:
Dependency (group members become dependent on one another and try to elicit
protection)
Pairing (it is hoped that the formation of a partnership in the group might bring forth a
new resolution)
Fight-flight (an attack or withdrawal mode)
massification/aggregation where a rigid fusion of identities leads to loss of
individuality, or extensive withdrawal leads to loss of mutual dependence.
Aspects of CBT groups
Group Cohesiveness: the degree of personal interest of the members for each other
Task Focus: goals are defined; tasks may include cognitive restructuring through
behavioural experiments
What are the four principles of TCs?
Communalism (Staff are not separated from inmates by uniforms or behaviours, mutual
helping and learning occurs)
Permissiveness (tolerating each other and realising unpredictable behaviour can happen
within the community)
Democratisation (shared decision making and joint running of the unit) and
Reality confrontation (self-deception or distortions from reality are dealt with honestly
and openly by all members without formalities).
Aim of IPT
Aims to improve interpersonal functioning and may be offered in conjunction with
medication. Conducted over 12-16 sessions. Involves giving ‘sick role’ to the patient.
Session of IPT?
12-16, weekly hour sessions
Premise of IPT?
Based on the premise that emotional problems are best understood by studying the
interpersonal context in which they arise. It is a time-limited, ‘here-and-now’ focused
therapy. Illnesses are viewed as ‘medical disorders’. Interpersonal events are not essentially
causal – but understanding their role in the illness and resolving the interpersonal problem
assists the route to recovery.
Focus of IPT?
the current interpersonal relationships and their relationship
to the development of illness. Inventory of all close relationships is created in early part of
therapy. The treatment lasts for 12 to16, hour-long weekly sessions.
Therapists stance in IPT?
the therapist is an explicit ally and advocate for the patient. The
therapist is nonjudgmental, expresses warmth and positive regard for the patient and
congratulates the patient as progress in the problem areas is made. The therapist works
with the patient and for the patient and believes that the patient’s problems can be solved.
This does not imply that the therapist accepts all aspects of the patient, as that would
preclude any stimulus for change. The therapist always tries to have the patient find the
solution for the problems discussed in the session. However, the therapist is not afraid to
make suggestions or provide direct advice when they seem useful.
Areas of focus in IPT
Role Transitions (e.g., job change, marriage)
Interpersonal disputes (e.g., conflicts at workplace, disputes with a family member)
Grief (loss of a loved object/relation)
Interpersonal deficits (e.g., unfulfilling relationships, social inadequacy)
Indications for IPT?
Mild - mod depression
Bulimia
How does IPT work in bulimia
a detailed assessment culminating in an
“interpersonal inventory” identifies core interpersonal problem(s) that become the focus of
treatment. Hence, IPT may be particularly helpful for clients who have become “stuck” in
their eating disorder for reasons associated with problematic relationships.
How does DBT work?
addresses the difficulties faced by a patient with BPD in a hierarchical fashion
starting from self-harming behaviours, moving on to therapy interfering behaviours and
later behaviours reducing the quality of life.
Four modes of DBT?
(1) group skills training, (2) individual
therapy, (3) phone consultations, and (4) consultation team
Key techniques in DBT?
Distress tolerance includes accepting, finding meaning for, and tolerating distress. This
includes crisis survival strategies such as distracting, self-soothing, improving the moment,
and thinking of pros and cons and acceptance skills such as radical acceptance, turning the
mind toward acceptance, and willingness versus willfulness.
Interpersonal effectiveness training is very similar to assertiveness and problem-solving
training.
Core mindfulness training - learning to monitor internal mental states.
Emotion regulation skills form an important part of DBT.
social skills training such as meditation, assertiveness training, etc.
Another approach commonly employed in DBT is validation - recognizing distress and
behaviours as legitimate and understandable but ultimately harmful.
Indications for CAT?
Depression
Anxiety
PD
Central concepts of CAT?
Procedural sequence models
Role-repertoires
What is the Procedural sequence model?
an attemptto understand aim-directed action. Any aim-
directed activity follows ordered sequences of aim generation, environmental evaluation,
plan formation, action, evaluation and, procedural revision. Some procedural sequences may
be faulty but repeated withoutrevision. These result in repetitive difficulties seen in some
psychiatric patients.
Describe some patterns in Procedural sequence model?
‘Traps’: seen as negative assumptions that produce consequences, which in turn reinforce
assumptions.
‘Dilemmas’: a person acts as though available actions or roles are limited or polarised.
‘Snags’: appropriate roles or goals are abandoned because others would oppose them, or they
are thought to be ‘forbidden’.
What is a restricted role repertoire?
Undue restriction in the total number / variety of procedural
sequences (repertoire) may occur due to the impoverished environment, childhood abuse,
etc. Such restricted repertoires lead to neurotic difficulties.
Structure of CAT
16-24 sessions in three phases.
Initial phase: an exploration of traps, dilemmas and snags. Therapist writes
formulation letter
Middle phase: working through problems with the use of diagrams exploring ‘target
problem procedures.’
Ending phase: both patient and therapist write goodbye letters
What does transactional analysis do?
Examine interaction between people
Key ideas in transactional analysis
there are 3 main ego-states people consistently use:
□ ‘Parent’ e.g., shouting at a colleague when they have made a mistake because this is
your own experience of how your parents behaved. This describes a ‘criticising’
parental state, but there may also be a ‘nurturing’ one: taking care of others, as though
they were children.
□ ‘Adult’ e.g., making an objective appraisal of reality, behaving in a
rational/reasonable way towards others
□ ‘Child’ e.g., getting into a strop if you are criticised for not doing something correctly.
This is also the source of emotions, spontaneity and creativity
Premise of humanistic psychotherapy
Humanistic therapists believe that that each of us has the responsibility for finding
meaning in our own lives. Therapy is seen only as a way to help people to make their own
life choices and resolve their own dilemmas. To help clients make choices, humanistic
therapists strive to increase emotional awareness.
There is a great deal of importance placed on the therapist-client relationship. Most other
approaches also recognize the importance of the therapist–client relationship, but they
view the relationship primarily as a means of delivering the treatment. But in humanistic
therapy, the relationship is the treatment.
Central aspect of client-centered therapy
A central aspect is the notion that “every individual has the motivation and ability to change,
and he or she is the best person to decide on the direction of change”. According to Rogers, if
clients are successful in experiencing and accepting themselves, they will achieve their own
resolution of their difficulties
Techniques of client-centered therapy
Non-directive; Because of this basic respect for the client’s humanity,
client-centered therapists avoid directing the therapeutic process. The client is encouraged to
focus on current subjective understanding. The therapist is encouraged to be warm, genuine
and to suspend judgement. The patient is believed to have vast resources to understand and
help him/herself, and the therapist’s goal is to facilitate this process.
Notion of self-concept; ‘the organised, consistent set of perceptions and beliefs
about oneself’. It emphasizes the importance of ‘therapeutic attributes of genuineness’,
‘unconditional positive regard’ and ‘accurate empathy’.
Unconditional positive regard involves valuing clients for who they are and refraining from
judging them.
The Q-sort technique developed from client centered therapy involves a person sorting cards
with statements on them into piles.
What is premise of gestalt therapy?
An existential and humanistic psychotherapy focussing the patient’s experience in the present
and emphasises personal responsibility.
Central aspects of gestalt therapy?
Phenomenological method: aims to increase awareness through repeated observations
and inquiry
Dialogical relationship: therapist attends to his/her own ‘presence’ and creates a space
for the client to do likewise. This can be described as ‘inclusion’: supporting the presence
of the client (including his/her resistance to being present)
Field-theoretical strategies: this includes a focus on both physical/environmental realities
of the client, and those related to the client’s mental processes and character structure
Experiential Freedom: a move towards action: trying something new, not just talking
about it
Central concepts of MBT
o Maintaining a curious/not knowing stance
o Understanding of the patient’s subjective experience through empathy
o Validating the patient’s experience.
o The goal is to increase the patient’s mentalizing capacities.
Key features of MBT
a. The therapist focuses on patients’ current mental state to build up representations of
internal states. The therapist avoids situations in which the patient talks of mental
states that cannot be linked to subjective reality. Thus, there is a deviation from
psychodynamic therapy in the following aspects:
i. De-emphasis of hidden unconscious concerns in favour of conscious or near-conscious
content
ii. Less focus on the past as it is represented in the present;
iii. The aim of therapy is not insight but the recovery of mentalization
iv. The therapist avoids describing complex mental states (such as conflict, ambivalence,
and unconscious) and is asked to make “minor interpretations” referring to ideation that
is only slightly beyond the boundaries of the patient’s conscious thinking.
b. Therapy creates a ‘transitional area of relatedness’ - here thoughts and emotions can
be trained.
c. Any enactments during treatment are not interpreted in terms of unconscious but in
terms of the situation and emotions immediately before the enactment.
Theory of EMDR
Premise: When a trauma occurs it seems to get locked in the nervous system with the
original picture, sounds, thoughts and feelings. This material can combine fact with
fantasy and with ‘images’ that stand for the actual ‘emotions’. The eye movements used in
EMDR ‘unlock the nervous system’ (desensitise) and allow the brain to correctly process
the experience (reprocessing).
This is based on a highly hypothetical surmise that REM sleep helps in processing the
unconscious material and reproducing eye movements that are seen in REM can induce a
similar process while awake.
What is transtheoretical model
This was developed largely in response to increasing divergence in the practice of
psychotherapy, and the authors attempted a (transtheoretical) synthesis among the
various therapeutic systems. They identified five common processes of change from
analyzing 18 psychotherapy models.
Five processes of change in transtheoretical model
Consciousness raising: helping the patient gather information about self and the problem
Choosing: increasing awareness of healthy alternatives,
Catharsis: emotional expression of the problem behaviour and the process of change,
Conditional stimuli includes stimulus control and counterconditioning,
o Stimulus control: Avoidance of stimuli associated with the problem behaviour
and the operant extinction cueing effect of the stimulus on behaviour.
o Counterconditioning: Training an alternative, healthier response to the cue
stimuli.
Contingency control: Positive reinforcement from others and self-appraisal and improving
self-efficacy by self-reinforcement.
Six stages of change in transtheoretical model
(1) precontemplation, (2) contemplation, (3) Preparation, (4) action, (5)
maintenance, and (6) relapse.
Principles of motivational interviewing
It is more effective to work collaboratively with patients rather than directly
challenge them to change their behaviour.
Resolving the ambivalence towards changing can increase intrinsic motivation to
change – this increase in motivation is the main goal of the motivational interview.
A change coming from the patient is more powerful than that prescribed by a
therapist.
Five principles of motiational interviewing
(1) express empathy, (2)
develop discrepancy, (3) avoid argumentation, (4) roll with resistance, and (5) support self-
efficacy.
What is behavioural couples therapy aimed at?
Specific intervention for alcoholism
Works directly to increase relationship factors conducive to abstinence
Number of sessions in behavioural couples therapy
Patient and the spouse are seen together in BCT for 15 to 20 outpatient couple sessions
over five to six months.
Structure of behavioural couples therapy
The therapist arranges a daily “sobriety contract” in which the patient states his or her
intent not to drink or use drugs that day (in the tradition of one day at a time), and the
spouse expresses support for the patient’s efforts to stay abstinent.
BCT increases positive feelings and constructive communication e.g., “Catch Your Partner
Doing Something Nice” is a part of BCT that asks spouses to notice and acknowledge one
pleasing behaviour performed by their partner every day.
Emphasis in ACT
Emphasises working on the way people relate to their thinking and feeling, rather than
directly trying to challenge or change this
Theoretical underpinnings of ACT
Cognitive fusion e.g.,. I think I am useless, this belief influences by behaviour (I don’t do
anything), therefore reinforcing my belief
Experiential avoidance e.g.,. I feel anxious, and instead of staying with the anxiety, I do
everything possible to avoid it
Strategies of ACT
Acceptance: taking a position of non-judgemental awareness towards thoughts,
feelings, sensations as they arise
Cognitive Defusion: the opposite of cognitive fusion e.g., I will try to step back and
observe my thoughts
Contact with the present moment: mindfulness forms the foundation for experiencing
the present moment
Self-as-context: e.g., ‘I think I’m useless. Therefore I am useless’- the person’s identity
is caught up in a particular thought
Values: patients are encouraged to explore their values: their deeper sense of purpose
and meaning; choice and freedom of action are the main focus
Committed action: learning to move in a valued direction, while in the presence of
unwanted or painful thoughts and feelings
Therapeutic stance in ACT
The clinician sidesteps ‘literal’ language and use metaphors,
paradoxes and experiential exercises ; the approach is more like that of a coach, helping
the patient get a feel of what is happening, rather than explaining how it works.
Conditions ACT can be used for
Depression Psychosis Substance abuse Chronic pain BPD
Who is Mindfulness based cognitive therapy aimed at
People vulnerable to repeated episodes of depression
Premise of Mindfulness based cognitive therapy
even after someone recovers from an episode of depression, even small
changes in mood can lead to large-scale negative thoughts and emotions, which can
trigger relapse. MBCT addresses this vulnerability.
Structure of Mindfulness based cognitive therapy
8 weeks of mindfulness classes
Education classes on depression
Exercises derived from cognitive therapy, demonstrating links between thoughts, emotions and bodily sensations
Outcome of Mindfulness based cognitive therapy
44% reduction in depressive relapse risk
What conditions does NICE recommend CBT for?
psychosis/schizophrenia, depression, anxiety disorders, eating disorders,
PTSD
What conditions does NICE recommend IPT for?
Eating disorders
Depression
What conditions does NICE recommend MBT for?
PD
What conditions does NICE recommend MBCT for?
Relapse prevention in depression
What conditions does NICE recommend psychodynamic therapy for?
Depression
Anxiety
PTSD
PD
What conditions does NICE recommend behavioural therapy for?
Addiction
What conditions does NICE recommend family therapy for?
Eating disorders
Psychosis/SCZ
Best predictor of outcome in any therapy
Degree of therapeutic alliance
What is cognitive restructuring in CBT?
Identifies negative thoughts, dysfunctional assumptions and maladaptive core beliefs and tests their validity.
Goal is to produce more adaptive and positive alternatives.
Techniques in cognitive restructuring of CBT
Identification of negative thoughts
Identification of dysfunctional or faulty assumptions
Identification of maladaptive core beliefs and rating their strength
Restructuring maladaptive core beliefs
Rating impact of these beliefs on ones emotion
Behavioural techniques used in CBT
Rehearsal to anticipate challenges and develop coping strategies
Graded assignment on exposure
Self-reliance training
Activity scheduling to increase positive activities and decrease avoidance
Diversion or distraction techniques
Structure of CBT
12-16 weekly sessions
Homework and assignments are set
At the start you are taught about CBT model Identify dysfunctional thoughts and core beliefs
Use of socratic questioning to challenge these thoughts, reveal their self-defeating nature and identify cognitive triad
Focuses on here and now and is time-limited
Outcomes measured by direct observation, standardised instruments and self report measures
Middle phase of CBT
Patient keeps dysfunctional thought diary
Homework assignments through which therapist identifies cognitive errors and core beliefs and patient practices skills to challenge these errors as well as identifying safety behaviours and entering fearful situations without these behaviours while applying relaxation techniques
Activity scheduling
Assertiveness training
Last phase of CBT
Identify early sx of relapse and situations which may trigger relapse
Taught coping skills to overcome negative emotions, interpersonal conflict and pressure
Consolidate skills learnt in therapy
First phase of CBT
Psychoeducation on CBT model on first session
Goals set for sessions
Negative automatic thoughts are identified and socratic questioning used
What is the cognitive triad in CBT
Negative thoughts of the self, world and future
Aim of cognitive restructuring
Identify negative thoughts, dysfunctional assumptions and maladaptive core beliefs relating to ones problems and test their validity, with the goal of producing more adaptive and positive alternatives
Questions for recent grief (IPT)
How are you coping with the loss?
Was the loss expected?
Questions for interpersonal disputes (IPT)
Is there anything in your life bothering you recently?
Tell me about your close relationships - any recent arguments?
Questions for role transitions (IPT)
Have there been any recent changes in your life? Work/family/home
Questions for interpersonal deficits (IPT)
Is there anyone you feel you can speak to about your problems?
How is your relationship with work colleagues/friends/family?
Goals of IPT
To create a therapeutic environment with meaningful relationship with the therapist and recognition of persons underlying attachment needs to develop understanding of their communication difficulties and attachment styles as well as identify their maladaptive patterns of communication.
Aim is to build better social support network and mobilise resources
First phase of IPT
Psychoeducation about model and disorder
Identify target interpersonal problems such as grief, interpersonal deficits, role dispute and role transition
Middle phase of IPT
Identify interpersonal problem areas and impact on mood
Create interpersonal inventory
Communication analysis to identify maladaptive patterns of communication
Developing role-play and strategies to handle similar situations in future
Role of therapist in IPT
Can be neutral, passive or advocate e.g. on correcting communication patterns
Treatment of grief in IPT
Explore feelings of loss of relationship/status
Facilitate mourning
Develop interests and relationships to substitute loss
Treatment of interpersonal disputes in IPT
Identify current stage of dispute and understand role of expectations
Modify non-reciprocal role expectations
Examine interpersonal relationships and assumptions behind the behaviour and modify faulty assumptions
Treatment for role transitions in IPT
Help in accept loss of previous role
Develop positive attitude towards new role and sense of mastery over new role
Treatment for interpersonal deficits in IPT
Reduce social isolation
Encourage formation of new relationships
Explain repetitive pattern of relationships
Termination phase of IPT
Discuss impact of termination including acknowledgement that it may trigger feelings of grief
Establishing competency to handle interpersonal problems independently after termination
Identify social support services
Structure of IPT
Time-limited, 16-20 sessions
Aims to improve interpersonal functioning and thus reduce suffering
Focus is on interpersonal relationships and helps patient to improve social support network and managing interpersonal distress
Questions for minimisation
Did you play a part in the previous success?Do you think you might have underestimated your contribution?
Questions for magnification
How have you done before? - Aren’t those successes important too?
What about overall?
Is that enough to ruin everything?
Questions for overgeneralization
How have things been outside of work/family etc?
Do yourself differently outside of work etc?
Question for selective abstraction
How do you feel about the success?
Question for personalisation
Why do you think it happened/who do you think is responsible?
What about everyone else in the team?
Do you think something else may have contributed?
Questions for arbitrary inference
What do your work colleagues/family think about you now?
How does this single failure/absence affect the outcome overall?
Questions for dichotomous thinking
It sounds like you feel either you are a complete success or failure; is there anything in between?
Questions for labelling
What does this loss say about you?
You call yourself a loser. Would you say the same about a work colleague if they did the same?
What does DBT consist of?
Mindfulness. This is a set of skills that focus your attention on the present, rather than worries about the past or the future. You might have a mindfulness module running between other modules. DBT sessions may often also start with a short mindfulness exercise. See our pages on mindfulness for more information.
Distress tolerance. This means learning to deal with crises without harmful behaviours, like self-harm.
Interpersonal effectiveness. This means learning to ask for things and say no to other people, with respect for yourself and others.
Emotion regulation. This is a set of skills you can use to understand, be more aware, and have more control over your emotions.
Concept of DBT?
DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from contemplative meditative practice.
The goal of DBT is to break this cycle by introducing 2 important concepts:
validation: accepting your emotions are valid, real and acceptable
dialectics: a school of philosophy that says most things in life are rarely “black or white” and that it’s important to be open to ideas and opinions that contradict your own
Give an example of a trap
You might feel, for example, that nobody ever listens to you. As a result, you stop talking about how you feel but this makes you miserable and isolated.
Others might notice this and ask what’s wrong, but you don’t tell them because you don’t think they’ll listen, which keeps the cycle going.
In the case of eating disorders an example might be bingeing in response to feeling bad about ourselves, but in turn feeling worse about ourselves because we have binged.
Letter written at start of CAT?
Reformulation letter - to put into words difficulties patient is having
Idea of PSM
That activities are aim directed and purposeful.
A procedural sequence or, more simply, a procedure, is the linked chain of mental processes and actions involved in the execution of aim-directed acts. As a unit of observation, a procedure combines perception, cognition, emotion and action, including how the person (consciously or unconsciously) predicts and evaluates the effects of his action and including in this evaluation the responses evoked in others. The model places particular emphasis on the role of feedback in confirming or revising the person’s aims and procedures. Neurosis is understood in terms of processes that perpetuate a person’s reliance on ineffective procedures or that lead to the inappropriate abandonment of aims. Common patterns of such self-perpetuating faulty procedures can be described as traps, dilemmas and snags
How to understand mental illness in terms of PSM in CATA
neurosis is understood as the persistent use of, and failure to modify, procedures that are ineffective or harmful. Snags represent, for example, the inappropriate abandonment of aims (stage 7), due to a true or false perception or prediction of negative outcomes. Dilemmas represent undue narrowing (false dichotomization) of the possible sub-procedures (stage 5). Traps represent the reinforcement of negative beliefs and assumptions (stages 2 and 3) by acting, (stage 5) in ways that evoke consequences which are, or are seen to be, confirmatory of negative assumptions (stages 6 and 7).
What is a snag?
This is a combination of thoughts, feelings and responses that lead a person to give up on, or sabotage something they want either because of the assumptions they make about what other people think and feel about them, or because they feel irrational guilt about anything that they allow themselves to have.
Sometimes this comes from how you or your family thought about you when we were young. Perhaps there were expectations in your family or community along the lines of ‘she was always the good child’, or ‘in our community we never ever…’. So a forbidding voice inside can get in the way of pursuing your aim.
Describe reciprocal roles in CAT
In CAT the reciprocal role is the basic way of understanding the relationship patterns that have developed for the individual from childhood and that are still present in the here and now. They tend to dictate the way that the individual finds themselves thinking, feeling and behaving, often in response to what they assume or anticipate someone else will do, think or say.
They are a stable pattern of interaction originating in relationships with caretakers in early life, and Procedures for dealing with relationships and self management
Difference between CAT and CBT
CAT focuses on past as well as present
CAT focuses more on emotions and relationships and early experiences
Main idea of CAT
through early experience we develop patterns of relating, including thinking, acting and feeling that can be adaptive at the time but later may become problematic
Causes of restricted role repertoire
mpoverished environmental opportunities for learning new procedures, for example in cases of emotional deprivation and neglect; deliberate attempts by caregivers to restrict procedural repertoires, for example by injunctions to secrecy in cases of sexual abuse;
Describe Restricted role repertoires
Ryle described how our early learning about the social world is stored in the form of internalised templates of reciprocal roles. These consist of a role for self, a role for other and a paradigm for their relationship. Reciprocal roles may be benign and functional or harsh and dysfunctional. Examples include caregiver/care receiver, bully/victim, admiring/admired and abuser/abused. In general, reciprocal roles are commonly shared templates. Therefore, when an individual takes up one pole of a reciprocal-role pairing, the person with whom he or she is relating feels pressure to adopt the congruent pole. When the roles in use are moderate and socially congruent this pressure to reciprocate remains largely unnoticed and is generally appropriate. However, in the therapeutic situation, where fewer environmental cues guide role choices and where the patient’s own reciprocal-role repertoire is both unusually harsh and emotionally extreme, the therapist can feel a strong pressure to reciprocate in ego-alien ways.
In normal individuals a wide range of flexible and adaptive reciprocal-role templates is deployed as needed. In people with borderline personality disorder only a small number of highly maladaptive reciprocal roles are available for deployment. This means that within any social situation these people have only limited and often inappropriate templates to call on when planning action.
What is in the reformulation letter in CAT
Many reformulation letters also contain a diagram that lays out the repertoire of reciprocal roles used by the patient, the procedural sequences that they deployed around those roles and the symptomatic consequences of those sequences. Patients respond to reformulation letters in a wide variety of ways, which are often related to their underlying problems. Very many of them find the experience of being written and thought about in this way both arresting and moving. They are, without exception, encouraged to annotate, improve, alter and interact with the reformulation letter in negotiation with the therapist until it can become the basis for the rest of therapy.
Describe goodbye letter in CAT
In the penultimate session the therapist gives the patient another letter, known as the goodbye letter. This briefly outlines the reason the patient came to treatment and recounts the story of the therapy. It tries to give an account of what has been achieved during therapy and also to mention things that have not yet been achieved. The letter outlines the therapist’s hopes and fears for the patient in the future, sketching out ways that understandings reached in therapy might be used helpfully. Many patients choose to give the therapist a goodbye letter of their own.
What other therapies is CAT based on
Cognitive
Psychoanalytical
What is target problem in CAT
Target problems are developed from presenting complaints. During the reformulation period,
there is an important process of converting a complaint into a target problem that involves
turning it into something do-able, manageable and preferably couched in interpersonal
language.
For example, the presenting complaint might be ‘chronic headache’, which in the process of
discussion could yield a target problem for therapy, for example: ‘I find it difficult to look
Glossary(of(CAT(terms(and(concepts. ©(Catalyse(September(2013 Page(3
after myself and keep myself well’. This process has already introduced some leverage i.e.
that it is difficult (but could change) and that it is something I am doing to myself (or feasibly
to another).
Target problems are underpinned by target problem procedures (TPPs). These are the
sequences of appraisal, emotion, aim, action, consequence and re-appraisal that maintain the
problem. For example, the target problem: ‘I find it difficult to look after myself and keep
myself well’ may be underpinned by this problem procedure, i.e. the whole sequence:
• feeling unwanted, inadequate and a failure (this appraisal driven by reciprocal roles
‘judgemental, critical’ to ‘undermined, inadequate’)
E.g. of RRR in CAT
When you
experience a harsh, critical parent, you learn what it is to be crushed and demoralised, feeling
not good enough. You also learn to be self-critical and to be critical of others. Each
reciprocal role procedure (RRP) can be enacted in three different ways: others do it to me, I
do it to myself, I do it to others.
