Psychotherapy 1.2 Flashcards
When were group methods developed?
Early 20th century
What led to the development of group methods?
Observations of beneficial group effects in TB patients
Who was the first major proponent to observe beneficial effect of groups?
JH Pratt
Who developed group methods?
T Burrow in the 1920s
What is the premise of group processes?
Behaviour and dynamics of the group cannot be derived from the individuals.
Once formed, groups develop their own way of existing.
What is group alliance?
Quality of relationships that develop between each member and the therapist.
What is group cohesion?
Group working together towards a common goal.
What is group coherence?
Group goes beyond cohesion and becomes self-evolving and able to work through conflicts.
What is positive identification?
Unconscious group mechanism in which a person incorporates the characteristics and qualities of the group.
What is catharsis?
Expression of ideas and conflicts is accompanied by an emotional response which produces a sense of relief.
How can group therapies be divided
According to degree of leadership
According to membership
According to mode of therapy
Which group therapies have high level of leader input and are highly specific
Structured groups for drug and alcohol misuse
Activity groups like OT
Which group therapies are highly specific but have low level of therapist activity
Problem-solving therapy
Psychoeducational groups
Which groups have low leadership level and low specificity of treatment goals
Support groups
Art therapy
Interpersonal therapy like Tavistock model analytic groups
What can groups be divided into according to mode of therapy?
Activity Support Problem-focused Psychodynamic Behavioural
What do analytic/dynamic groups involve?
Examination of the conscious and unconscious processes in the group including resistance, transference and countertransference
What did Bion describe?
Three basic states that a group goes into when it gets derailed
What are the three states described by Bion?
Dependency
Pairing
Fight-flight
What are the three states described by Bion known as?
Basic assumption
What is the 4th basic assumption introduced by Hopper?
Massification/aggregation
What happens in dependency?
Group members become dependent on one another
What happens in pairing?
Formation of a partnership in the group might bring forth new resolution
What is massification/aggregation?
Regid fusion of identities leads to loss of individuality or extensive withdrawal leads to loss of mutual dependence
What did Foulkes describe?
Group matrix; web of communications and relationships within a group
What did Foulkes divide the group matrix into?
Foundation matrix
Dynamic matrix
What is the foundation matrix?
Commonalities existing between strangers attributable to characteristics of human species
What is the foundation matrix a precondition of?
Later evolving dynamic of group matrix
What is the dynamic matrix?
Ever developing exchanges that occur between group members
Factors that influence a group matrix
Mirroring Exchange Free floating discussion Resonance Translation
What did Yalom cite?
11 curative factors responsible for change in groups
What are the 11 curative factors according to Yalom?
Instillation of hope Universality Imparting information Altruism Corrective recapitulation Socialisation techniques Imitative behaviour Interpersonal learning Group cohesiveness Catharsis Existential factors
Name some expressive therapies
Psychodrama
Art therapy
Music therapy
Support groups
Who created psychodrama?
Moreno
What happens in psychodrama?
Therapist acts as the director
Patient as protagonist
Another group member as someone significant in the patients life (auxiliary ego)
Soliloquey as a recital of thoughts and feelings
What is role reversal in psychodrama?
Exchange of patients role for role of significant person
What is ‘double’ in psychodrama?
Auxiliary ego acting as the patient
What is ‘multiple double’ in psychodrama?
Several egos acting as the patient
What is ‘mirror technique’ in psychodrama?
Auxiliary ego imitating the patient and speaking in the proxy
Most important component of music therapy?
Therapeutic alliance
Important aspects of cognitive behavioural groups?
Group cohesiveness
Task focus
Principles of therapeutic communities is based on what?
Henderson hospital model
Major components of therapeutic communities?
Communalism
Permissiveness
Democratisation
Reality confrontation
What is communalism?
Staff not separated from patients
Mutual helping and learning
What is permissiveness?
Tolerating each other and realising unpredictable behaviour can happen in the community
What is democratisation?
Shared decision making and joint running of the unit
What is reality confrontation?
Self-deception or distortions from reality are dealt with honestly and openly by all members
Who created interpersonal therapy?
Klerman & Weissman
Aim of interpersonal therapy?
Improvement of interpersonal functioning
How many sessions are involved in interpersonal therapy?
12-16
What is the patient seen as in interpersonal therapy?
The sick role
What is interpersonal therapy based on?
The idea that emotional problems are best understood by studying the interpersonal context in which they arise.
Focus of interpersonal therapy?
Current interpersonal relationships and their relationship to development of illness
Therapists stance in IPT
Advocate for patient
Areas of focus in IPT
Role transitions
Interpersonal disputes
Grief
Interpersonal deficits
Which disorders is IPT indicated for?
Mild to moderate depression
Bulimia
Who created DBT?
Marsha Linehan
Aim of DBT
Reduce self-harm in BPD
How does DBT address problems of patients with BPD?
Uses hierarchical fashion starting from self-harming behaviours, then therapy interfering behaviours and later behaviours reducing QoL.
Modes of DBT?
Group skills training
Individual therapy
Phone consultations
Consultation team
Key techniques of DBT
Distress tolerance
Interpersonal effectiveness
Core mindfulness
Emotion regulation skills
What happens in distress tolerance?
Accepting, finding meaning for and tolerating distress.
What is interpersonal effectiveness training?
Assertiveness and problem solving training
What is core mindfulness training?
Learning to monitor internal mental states
What is another approach used in DBT>
Validation - recognising distress and behaviours as legitimate and understandable but ultimately harmful
Who created cognitive analytic therapy?
Anthony Ryle
Which psychiatric disorders can CAT be used for?
Depression
Anxiety
PDs
Central concepts of CAT?
Procedural sequence model
Role-repertoires
What is procedural sequence model?
Attempt to understand aim-directed action.
What do aim-directed actions consist of?
Aim generation Environmental evaluation Plan formation action Evaluation Procedural revision
What patterns are seen in patients under the procedural sequence model?
Traps
Dilemmas
Snags
What are traps?
Negative assumptions that produce consequences which in turn reinforce assumptions.
What are dilemmas?
A person acts as though available actions are limited or polarised.
What are snags?
Appropriate roles or goals abandoned because others would oppose them or thought to be forbidden
What is restricted role repertoire?
Undue restriction in number/variety of procedural sequences may occur due to impoverished environment, childhood abuse etc.
These lead to neurotic difficulties.
Duration of CAT
16-24 sessions in three phases
What are the phases of CAT
Initial
Middle
Finding
What happens in the initial phase of CAT?
Exploration of traps, dilemmas, snags
Therapist writes formulation letter
What happens in middle phase of CAT?
Working through problems with diagrams exploring target problem procedures
What happens in final phase of CAT?
Therapist and patient write goodbye letters
Difficulties in using CAT for BPD
Those with BPD have a small number of highly maladaptive reciprocal roles.
Patients with BPD are oversensitive to stimuli resulting in unwarranted changes
Capacity for conscious self-reflection and control is impaired in BPD.
What is the reciprocal role in CAT?
When subject assumes one pole the opponent is pressurized to take up the opposite pole to interact
Who created transactional analysis?
Eric Berne
What does transactional analysis do?
Examines interactions between people
Key ideas of transactional analysis?
There are three main ego states:
Parent
Adult
Child
What is the parent ego state?
Criticising or nurturing parental style
What is the adult ego state?
Examples include making an objective appraisal of reality or behaving in a rational way towards others
What is the child ego state?
Source of emotions, spontaneity, creativity.
Impulsive behaviour
How was humanistic psychotherapy originally promoted as?
Third force in psychotherapy
What do humanistic therapists believe?
Each person has a the responsibility for finding meaning in our own lives.
Therapy is a way to help people make their own life choices.
What do humanistic therapists strive for in therapy?
To increase emotional awareness
What is seen as the treatment in humanistic psychotherapy?
The therapeutic relationship
Who created client-centred therapy?
Carl Rogers
What is the central aspect of client-centred therapy?
Every individual as the motivation and ability to change and they are the best person to decide on the direction of that change.
How do clients resolve their difficulties according to Carl Rogers?
By experiencing and accepting themselves
What does it mean that client-centred therapy is nondirective?
Client is encouraged to focus on current subjective understanding.
How is the patient viewed in client centred therapy?
The patient has vast resources to understand and help themselves and the therapists goal is to facilitate this
What is the notion of self concept emphasised in client centred therapy?
The organised, consistent set of perceptions and beliefs about onself
What three things are emphasised in client centred therapy?
Therapeutic attributes of genuineness
Unconditional positive regard
Accurate empathy
What is unconditional positive regard?
Valuing clients for who they are and refraining from judgement
What developed from client centred therapy?
Q-sort technique
Who created Getalt therapy?
Perls and Goodman
What does Gestalt therapy focus on?
Patients experience in the present and emphasises personal responsibility
Central aspects of Gestalt therapy
Phenomenological method
Field-theoretical strategies
Experiental freedom
What is the phenomenological method?
Aims to increase awareness through repeated observation and inquiry
What is the dialogical relationship?
Therapist attends to their own presence and creates a space for the client to do likewise. This is described as inclusion; supporting the presence of the client
What are field-theoretical strategies?
Focus on both physical/environmental realities of the client and those related to the clients mental processes and character structure
What is experiental freedom?
A move towards action
Who created Mentalization based therapy?
Bateman and Fonagy
What is Mentalization based therapy derived from?
Attachment theory
Central concepts of Mentalization based therapy
Maintaing a curious stance
Understanding the patients subjective experience through empathy
Validating the patients experience
What is the goal of mentalization based therapy?
To increase the patients mentalizing capacities
How did mentalization based treatment start off?
As treatment for BPD in a psychoanalytically oriented partial hospitalisation programme
Key features of MBT
Therapist focuses on patients current mental state to build up representations of internal states.
Therapy creates a transitional area of relatedness
What is the transitional area of relatedness?
Where thoughts and emotions can be trained
How are enactments during treatment perceived in MBT?
As terms of the situation and emotions immediately before the enactment
In what ways is MBT a derivation from psychodynamic therapy?
De-emphasis of hidden unconscious concerns in favour of conscious content
Less focus on the past, more on present
Therapist avoids describing complex mental states
Who created EMDR?
Shapiro
What is the premise behind EMDR?
When trauma occurs it gets locked in the nervous system with original pictures, sounds, images, thoughts and feelings. This material can combine fact with fantasy and ‘images that stand for actual emotions.’
Eye movements in EMDR unlock the nervous system and allow the brain to correctly process the experience
What is the hypothesis behind the EMDR theory
REM sleep helps in processing unconscious material and reproducing eye movements in REM can induce similar process while awake.
When was EMDR originally used?
With Vietnamese war veterans suffering from PTSD
Who created the Transtheoretical model?
Prochaska and DiClemente
What was the transtheoretical model developed in response to?
Increasing divergence in the practice of psychotherapy
What common processes did the transtheoretical model identify amongst 18 models?
Consciousness raising Choose Catharsis Conditional stimuli Contingency control
What is consciousness raising?
Helping the patient gather information and self and the problem
What is choosing?
Increasing awareness of healthy alternatives
What is catharsis in transtheoretical model?
Emotional expression of problem behaviour and process of change
What is conditional stimuli?
Stimulus control and counterconditioning
What is stimulus control
Avoidance of stimuli associated with problem behaviour
What is counterconditioning in transtheoretical model
Training an alternative, healthier response to stimuli
What is contingency control?
Positive reinforcement and self appraisal, improving self-efficacy by self-reinforcement
What are the six stages of change in the transtheoreticalmodel?
Precontemplation Contemplation Preparation Action Maintenance Relapse
What happens in the precontemplation stage?
Person is not considering changing their behaviour
Do not see behaviour as a problem
Minimise and deny risks
Avoid information to the contrary
What happens in contemplation stage?
Person is aware of why the behaviour is a problem but is ambivalent about changing
Sees equal or more benefits than costs from behaviour
What happens during preparation stage?
Person has made a decision to change and is planning a strategy for change but has not yet taken action
What happens in maintenance?
Person is able to sustain change and avoid reverting to problem behaviour for significant period of time
Who created Motivational Interviewing?
Miller and Rollnick
What is Motivational Interviewing used with?
TTM
Stages of change
How did Miller and Rollnick develop motivational interviewing?
In line with client centred therapy
Work with substance-abusing patients
Major principles of motivational interviewing?
More effective to work collaboratively with patients than to challenge their behaviour
Resolving ambivalence towards changing can increase motivation to change
Change from the patient is more powerful than that prescribed by a therapist
Aim of motivational interviewing
Increase in intrinsic motivation to change
General principles of motivational interviewing
Express empathy Develop discrepancy Avoid argumentation Roll with resistance Support self-efficacy
What is behavioural couples therapy used for?
Alcoholism
What does behavioural couples therapy work to do?
Increase relationship factors, which is conducive to abstinence
Structure of behavioural couples therapy
Patient and spouse are seen together for 15-20 sessions for 5-6 months
What happens in BCT?
Therapist arranges a daily sobriety contract and spouse expresses support
What can BCT lead to?
Increase in positive feelings and constructive communication
What is acceptance and commitment therapy part of?
Third-wave CBT
What does acceptance and commitment therapy draw upon?
Basic account of language
What does acceptance and commitment therapy emphasise?
The way people relate to their thinking and feeling
Theoretical underpinnings of acceptance and commitment therapy
Cogitive fusion
Experiental avoidance
Give an e.g. of cognitive fusion
I think I am useless, this belief influences my behaviour, therefore reinforcing my belief
Give an e.g. of experiential avoidance
I feel anxious, instead of staying with the anxiety I do everything to avoid it
Strategies of acceptance and commitment therapy
Acceptance Cognitive Defusion Contact with the present Self-as-context Values Committed action
What happens in acceptance?
Taking position of non-judgemental awareness towards feelings, thoughts and sensations
What happens in cognitive defusion?
Stepping back and observing ones thoughts
What happens in contact with the present?
Mindfulness to experience the present moment
What happens in self-as-context?
Persons identity is caught up in a particular thought ‘I am useless’
What happens in values?
Patients are encouraged to explore their values, sense of purpose and meaning.
Choice and freedom are main focus
What happens in committed action?
Learning to move in a valued direction while in the presence of unwanted thoughts and feelings
Therapeutic stance in acceptance and commitment therapy
Clinician uses metaphors, paradoxes and experiental exercises
Which psychiatric disorders is acceptance and commitment therapy effective for?
Depression Work stress Psychosis Substance abuse Chronic pain BPD
Who developed mindfulness based cognitive therapy?
Segal and Teasdale
Who is mindfulness based cognitive therapy aimed at?
People vulnerable to repeated episodes of depression
Structure of mindfulness based cognitive therapy
8 weeks of mindfulness classes
Education classes
Exercises from cognitive therapy
What happens in education classes in mindfulness based cognitive therapy?
Learning about depression
What do exercises from cognitive therapy help with?
Demonstrate links between thoughts, emotions and bodily sensations
Evidence of impact of mindfulness based cognitive therapy on depression?
44% reduction in depressive relapse risk
Who does NICE recommend mindfulness based cognitive therapy for?
People who are well but who have experienced 3 or more past depressive episodes
Which factors make psychotherapy easy to measure?
Fixed duration Standardised by use of manuals Random assignment Patients have a single specifically-selected problem Outcome is measured in symptom counts
What are variations in outcome of psychotherapy thought to be due to?
Severity of disorder
Clinician and context-related factors
What is considered one of the most important factors in the effectiveness of psychotherapy?
The therapeutic alliance
Who does NICE recommend CBT for?
Psychosis Depression Anxiety ED PTSD
Who does NICE recommend interpersonal therapy for?
Depression
ED
Who does NICE recommend Mentalisation Behavioural Therapy for?
PD
Who does NICE recommend CAT for?
Depression
Anxiety
OD
Who does NICE recommend psychodynamic psychothapy for?
Depression
Anxiety
PTSD
PD
Who does NICE recommend behavioural psychotherapy for?
Addiction disorders
Who does NICE recommend family/systemic therapy for?
ED
Psychosis
Best predictor of outcome of any psychotherapy?
Degree of therapeutic alliance
Who conducted a meta-analysis of psychotherapies and pharmacotherapies?
Huhn et al 2014
For which psychiatric disorders has combination therapy found to be effective (therapy and medication)?
Depression
Social phobia
Panic Disorder
Bulimia
Which psychiatric disorders were found to have greater efficacy with medication treatment?
Schizophrenia
Dysthymia
Benefits of combined psycho-pharmacotherapy
Improved recovery rates Faster responses Decreased rate of relapse Improved long-term social functioning Improved medication compliance Greater reported satisfaction Lower long-term service costs
Challenges in offering combined therapies
Higher administration costs
Lack of reliable evidence base
Practical difficulties in co-administration
Difficulties in comparing trials of psychotherapy with pharmacotherapy
General psychotherapy trials have small sizes and larger effect sizes with compared to controls
Individual pharmacotherapy trials have large sample sizes
Psychotherapy trials have lower drop out rates and better quality of follow-up data
Researcher allegiance
Psychotherapy research do not often report authors conflict of interest
What is researcher allegiance?
Testing of psychotherapy by its inventors often positively influences the effect size
