Psychotherapy and ECT

Question 1

Psychological treatments

Answer 1

Use of the power of words to improve the physical and emotional
status of patients; Improve Morale, Engage with Self-Care, Encourage Concordance and
Reassurance of Return to Normalcy

• Aim to maximise patient’s Functioning and Independence wherever possible; Self-
management is cornerstone to most management of Psychiatric illness

Question 2

Therapeutic Relationship

Answer 2

Patients should feel Professional is concerned about them,
Makes time for them; Clearly distinct from Friendship
Establish with the patient the need to transition toward Independence; Recognise
that transition can be frightening but encourage to believe it is possible

Question 3

Therapeutic Relationship: Dependence

Answer 3

Caution when patient asks questions about practitioner’s personal life,
efforts to prolong interview beyond agreed time, contacts practitioner for
unwarranted reasons, new or increased problems presenting when reduction of
therapy is discussed and repeatedly bringing/offering gifts
o Dependence is counterproductive to therapy; Clear professional boundaries need to
be established and maintained

Question 4

Transference

Answer 4

Intense Relationship between patient and practitioner; Originally from
Freudian theory; Patient’s feelings and thoughts are transferred to the practitioner

Question 5

Countertransference

Answer 5

In the opposite direction; Impairs practitioner’s ability to

maintain appropriate professional relationship

Question 6

Other Psychological Techniques

Answer 6

• Patients concerns should be actively listened to; Adequate time, Undivided Attention and
Understood; Nonverbal signs of Attention and Summarising/Checking
• Allow release of Emotion with reassurance – Offer support with non-verbal and verbal
communication; Aim to improve morale after by discussing the way forward
• Improving Morale – Especially hopelessness with Prolonged and Recurrent Issues; Provide
Optimism by suggesting appropriate measures forward and support available
• Review and Develop Personal Strengths – Ensure what Abilities and Social Support that is
intact are taken advantage of
• Actively Endorse, Encourage and Facilitate Self Help

Question 7

Stepped Care in Psychotherapy

Answer 7

• Different intensities of treatment to triage according to need
• L1 – Psychoeducation, Self-Help approaches; Minimal Input by professionals
o Psychoeducation – Nature, likely causes, Help Available and Self-Help
o Bibliotherapy – Reading material suitable for level of knowledge, motivation and
nature of clinical problem
o Adherence improved with providing clear rationale, Actively Endorsing, suggesting
specific chapters or sections, and making a Follow up (e.g. 2/52)
• L2 – Group Treatment or Supported, Computerised Delivery e.g. CCBT
• L3 – Individual Treatment; In person, one-to-one
• L4 involves specialist and particularly intensive treatments

Question 8

Counselling

Answer 8

– Wide range of less technically complicated Psychological Treatments; ranges from Advice Giving, Sympathetic Listening, Structured Encouragement for problem solving

Question 9

Problem Solving Treatments

Answer 9

Helps patients solve stressful problems and make changes
o Main treatment for Stress and Adjustment Disorder; Typically for problems requiring
Decision Making, Adjustment or Change
o Defining, Listing, Choosing, Generating and Evaluating Solutions, Trial of Chosen
Solution, Evaluation and Resolution

Question 10

Crisis Intervention

Answer 10

For Overwhelming Stressful/Adverse Circumstances;
▪ Often DSH or Victims of Abuse
▪ Prompt, Brief and Goal-directed; Risk Assessment is Crucial; Expression of
Distress, Support, Encouragement to seek Social Support, Coping
Mechanisms and Adaptive Mechanisms
▪ Avoiding Maladaptive Behaviours (E.g. Avoidance, Substance Use)
▪ Management of Sleep Disturbance

Question 11

Behavioural Therapy

Answer 11

Aim to Alter Patterns of Behaviour; Useful for symptoms/Abnormal Behaviours which persist
due to actions of the patient or others that produce immediate relief, but prolong disorder

Question 12

Distraction Approaches

Answer 12

Reduce Impact of Worrying Thoughts and Preoccupations
o External Objects, Mental Exercises
o Building activities that are inherently distracting e.g. Lifestyle changes

Question 13

Relaxation Approaches

Answer 13

Reduce Anxiety by reducing Muscle Tone and Autonomic Arousal;
Also, useful for physical conditions made worse by stressful events
o Relaxation of Muscle Groups Individually, Breathing Exercises, Clearing the mind of
worrying thoughts through concentrating on calming images
o Resumption of activities after, as if awakening from sleep
o Also available as audio recorded programmes, or other resources

Question 14

Graded Exposure

Answer 14

Mainly for Phobic Disorders; In vivo or In Imagino; Graded exposure with
the aim towards Desensitisation
o Establish Hierarchy of fear; Starting at lowest rung, enter situation and monitor
anxiety, ensuring exposure until anxiety has subsided significantly

Question 15

Response Prevention

Answer 15

Mainly for Obsessional Rituals; Rituals become less frequent and
intense when patients make prolonged and repeated efforts to suppress
o Ritual must be suppressed until associated anxiety has waned; Initially, might lead to
increased anxiety and might require support
o Procedure repeated in response to factors which might provoke rituals
o Obsessional Thoughts tend to improve as rituals improve

Question 16

Thought Stopping

Answer 16

– Treatment of Obsessional Thoughts without Rituals; A sudden, intrusive
stimulus is used to interrupt thoughts, when aim to achieve similar effect without stimuli
• Assertiveness Training, Self-Control Techniques (Monitoring and Reinforcement)

Question 17

Contingency Management

Answer 17

Controlling Abnormal Behaviour which is reinforced unwittingly
through other people; Identifying Behaviour, Triggers and Reinforcers; Ignoring Undesired
Behaviour and Rewarding Appropriate Behaviour

Question 18

Cognitive Therapy

Answer 18

• Treatment of Symptoms and Abnormal Behaviours that persist because of the way patients
think about them; False Beliefs which can become maintaining factors
• Identification of Maladaptive Thinking (and records e.g. Dysfunctional Thought Record),
Challenging Maladaptive Thinking with accurate information and logical thinking, Devising
Realistic Alternatives to Maladaptive Thinking and Trial of Alternatives
• Combination with Behavioural Therapies to form CBT

Question 19

Cognitive Behavioural Therapy

Answer 19

• Delivered by specialised practitioners; Collaborative; Therapist helps patients first become
aware of, and modify Maladaptive Thinking and Behaviour
• CBT concepts can be applied to everyday clinical context – Recording Thoughts, Recording
Abnormal Behaviours and Events (Antecedents, Behaviours, Consequences), and asking
patient to monitor and record progress (Judging success of treatment, and Increasing
Collaboration and Concordance)

Question 20

Cognitive Behavioural Therapy: Homework

Answer 20

Homework – Patients practise new ways of Thinking and Behaving between sessions
o Written instructions often supplementing explanations
o Symptoms, Cognitions and Associated Behaviours recorded in Diary/DTR; Noting
down preceding/triggering factors, and subsequent/reinforcing factors

Question 21

Cognitive Behavioural Therapy: Other Treatment

Answer 21

• Treatment takes the form of Graded tasks and activities for patients to gain confidence with
less severe problems before more severe ones

• Tasks and Activities are presented as Experiments; Achieve of Goals =Success, Non-
achievement is not failure but opportunity to learn what went wrong

o Prevents discouragement and maintains motivation for therapy
o Behavioural Experiments – Used to test out patient’s predictions (E.g. due to negative
cognitive biases) to identify what will happen in specific circumstances

Question 22

CBT for Anxiety Management

Answer 22

Assessment, Relaxation, Techniques for changing Anxiety- provoking Cognition and Exposure Therapy

Question 23

CBT for Panic Disorder

Answer 23

Psychoeducation, Self-Monitoring, demonstrating that fearful

cognitions induce Anxiety, encouraging patient to think in new way and trial

Question 24

CBT for Depressive Disorder

Answer 24

Disruption and Modification of Intrusive Thought, Recognition
of Irrational, Illogical ideas and changing them into Realistic Thought, and Challenging
Maladaptive Assumptions
o Including Activity Scheduling as a behavioural intervention

Question 25

Dynamic Psychotherapy

Answer 25

• Patients helped to obtain a greater understanding of aspects of their problems and
themselves to help overcome their problems; Focus is onto aspects of Problems and Self
which the patient are previous unaware (Unconscious Aspects)

Question 26

Brief Focal Psychodynamic Therapy

Answer 26

Low Self-esteem and Difficulties forming relationships,
either accompanied by Emotional, Eating or Sexual Disorders
o Need to be insightful and willing to consider Links between Present Difficulties and
Events at Earlier Stages of Life
o Agreement on problems to focus onto, Discussion of Recent and Past Experiences of
the problem; Review their contribution to the problem and Common Themes
o Recall of Similar Problems at Earlier Stages of life; Especially, Maladaptive Behaviour
which may has originated initially as a way of coping
o Therapist makes Interpretations to help patients draw linked between Behaviours;
Interpretations should be Hypotheses rather than Truths to be accepted
o Patient encouraged to consider Alternative Cognitions and Trial

Question 27

Long Term Dynamic Psychotherapy

Answer 27

Aims to change Long-standing Patterns of Thinking and
Behaviour that contribute to Personal and Relationships problems
o Multiple times weekly for at least a year; Issue of Transference
o Free Association – Thoughts allowed to wander
o Recall of Dreams and Discussion of their meaning
o Interpretation of Transference – As a reflection of Patients Relationships with Parents
in Earlier Life; Helps patient practice controlling strong emotions
o Control of Countertransference on part of the therapist

Question 28

Other Modalities of Psychological Treatment

Answer 28

• Group Treatment – Either due to efficiency of delivery, or the Therapeutic group dynamic
• Couple and Family Treatment – Useful when core issue is related to these relationships

Question 29

ELECTROCONVULSIVE THERAPY

Answer 29

• Current applied to skull of Anaesthetised patient to produce seizure activity, while motor
effects are prevented with Muscle Relaxant
o Bilateral or Unilateral Electrodes; Unilateral application on Non-Dominant Side might
lead to less memory impairment, but might be less effective
o Beneficial effect believed to be due to Neurotransmission changes, especially
Monoamines; Acts faster than Antidepressants along similar long-term outcomes

Question 30

ELECTROCONVULSIVE THERAPY Main Indications

Answer 30

Urgent Response required (Life-Threatening e.g. Refusal to drink, eat or
has very intense Suicidal Ideation, or Puerperal Psychosis), Resistant Depressive Disorder,
Catatonic Schizophrenia or Depressive Stupor

Question 31

ELECTROCONVULSIVE THERAPY Adverse Effects

Answer 31

Brief Headache after; Degree of Cognitive Impairment occurs, although
clears rapidly for most; Some report Persistent Loss of Autobiographical memories
o Anaesthetic Complications – Teeth, Tongue or Lops might be injured; Apnoea from
Muscle Relaxants Rarely; Mortality from Anaesthesia and higher risk if CVS

Question 32

ELECTROCONVULSIVE THERAPY CI

Answer 32

Anaesthetic Issues, Cardiovascular and Arrhythmia issues

Question 33

Ethical issues

Answer 33

Informed Consent required, unless Incapacitated; Second opinion required if
wanting to perform ECT in Life-threatening Situations against patient’s wishes