Therapies Flashcards
What is FORMULATION?
- the process of making sense of a person’s difficulties in the context of their relationships, social circumstances, life events and the sense that they have made of them
- like a personal story or narrative that a psychologist or other professional draws up with an individual (and in some cases their family & carer)
What happens in FORMULATION?
- co-construct the personal meaning of the client’s life story
- summarise the client’s core problems in the context of psychological theory and evidence
- and thus indicate the best path to recovery
- developing a shared understanding of what is going on
- not like a diagnosis by focusing on the deficits
- instead, focus on the strengths and talents in surviving
Important thing to remember about FORMULATION?!
> It is an ADDITION to diagnosis, not an ALTERNATIVE to diagnosis
> Culture plays a big part!
FORMULATION and Culture
- really needs to be taken into account!
- should be considered with every service user
- there are certain disadvantaged group
> black and minority ethnic groups
> refugee and asylum seeker populations - language and religion - may be contributing barriers to treatment
> certain things / questions may not be or get asked
> these could be crucial for future reference
Cultural Formulation Model
- have to take into account the cultural identity of the service user -> language preference and degree of involvement with both the culture of origin and host culture!
- for the service user, it has to be their preferred explanation of their difficulties!
- cultural factors relate to both stresses and levels of support in the service user’s psychosocial environment
- cultural elements of the relationship between the individual and the clinician and their impact of the therapeutic relationship
Describe COGNITIVE BEHAVIOURAL THERAPY - background information
- an umbrella term - not a specific approach
- there are multiple approaches
Behaviour therapy:
- Behaviour Modification Therapy; Classical / Operant Conditioning
Cognitive therapies:
- psychotherapy owned at changing way of thinking
What are the different variations of CBT?
Rational Emotive Behaviour Therapy Rational Behaviour Therapy Rational Living Therapy Cognitive Therapy Dialectic Behaviour Therapy
Beck et al (1979) - COGNITIVE BEHAVIOUR THERAPY
- negative emotions are elicited by cognitive processes developed through influences of learning & temperament
- adverse life events elicit automatic processing - viewed as the causal factor
- -> starts off these repetitive negative thoughts
- cognitive triad!!!
- focus on examination of cognitive beliefs and developing rational responses to negative automatic thoughts
Diagnosis vs Formulation - Johnstone (2011)
DIAGNOSIS
- removes meaning
- removes agency (‘sick role’)
- removes social context
- individualises
- keeps relationships stuck
- expert-derived
- stigmatising
- emphasis on pathology
- culture and value blind
- medical consequences
- social consequences
Diagnosis vs Formulation - Johnstone (2011)
FORMULATION
- creates meaning
- promotes agency
- includes social contexts
- includes relationships
- promotes relationship change
- collaborative
- non-stigmatising
- includes strengths
- culture and value aware
- no medical consequences
- no social consequences
Beck - Cognitive Triad
Negative automatic thoughts centre around our understanding of:
- ourselves
- others (the world)
- future
Maintained by:
- cognitive biases
- negative self-schemas
Beck (1993) - CBT quote
“is best viewed as the application of the cognitive model of a particular disorder with a use of variety of techniques designed to modify dysfunctional beliefs and faulty information processing characteristic of each disorder”
Forman and Herbert (2006) - what are the fundamental aspects of the CBT model?
- theory of aetiology
- therapeutic strategies / techniques
- desired outcomes
Depression and CBT
- how does CBT apply to this disorder?
- negative view of the self, others and the future
- core beliefs - helplessness, failure, incompetence and feeling unloved
Negative triad associated with depression:
- SELF - “I am incompetent / unlovable”
- OTHERS - “People do not care about me”
- FUTURE - “The future is bleak”
Anxiety and CBT
- how does CBT apply to this disorder?
- overestimation of physical and psychological threats
- core beliefs - risk, dangerousness, uncontrollability
Negative triad associated with anxiety:
- SELF - “I’m unable to protect myself”
- OTHERS - “People will humiliate me”
- FUTURE - “It’s a matter of time before I am embarrassed”
CBT - Automatic Thoughts
- spontaneous in response to a situation
- occur in shorthand - words or images
- -> do not arise from reasoning
- -> there is no logical order to them
- very hard to switch off to
- difficult to articulate
Stressful situation –> Automatic thoughts –> Negative emotions
CBT - Cognitive Errors
Emotional reasoning
- well how I am feeling must be true / a fact
Anticipating negative outcomes
- the worst is going to happen
All-or-nothing thinking
- all will be good / all will be bad
Mind-reading
- knowing what others are thinking - they must be thinking that is how I am / feeling
Personalisation
- excess responsibility - its always my fault
Mental filter
- ignoring all the positives, only selecting to focus on the negative things
Catastrophizing
Black or White thinking
CBT - Core Beliefs / Schemas
What are schemas?
Schemata - cognitive structures which enable the individual to categorise and interpret experiences in a meaningful way
(screening, filtering, making decisions, driving patterns of behaviour)
- these assumptions influence information processing and organise understanding about ourselves, others and the future
CBT - Core Beliefs / Schemas
- these develop as a part of normal cognitive development
- do not necessarily cause emotional disorders
- BUT they are crucial to the contribution / continuance in the maintenance of chronic problems
- CAN be very negative and traumatic to the individual
- core beliefs - remain dominant until activated by stress or negative life events
Core beliefs —-> Automatic thoughts
- core beliefs can shape these automatic thoughts that we have
CBT - Core Beliefs
Blackburn (1998)
- helpless core beliefs; unlovable core beliefs; worthless core beliefs
SO
- core beliefs / schemas and early life events and childhood can be added into the CBT model
- can contribute to the thoughts that fuel our reactions, feelings and behaviours
CBT - Responding to Negative Thoughts
Essentially an evaluation of the situation!
Have to clarify the meaning of the cognitive appraisal
- -> what was going through your mind just then?
- -> what did the situation mean for you?
Evaluate the personal interpretation of the situation
- evidence - for & against this belief?
- alternatives - any other explanations
- implications - so what…….?
CBT - Homework methods employed
Example….
e.g. Thought records
Identifying the:
SITUATION - (when/where/what/who?)
EMOTIONS - (what did you feel? rate this emotion in %)
NEGATIVE THOUGHTS - (what you thought just before you started thinking like that?)
CBT - Homework methods employed
- tracing feelings back to before the thought started
- takes time to disentangle feelings from the thoughts
> the way you think is not the way you feel!!!!! - putting things into perspective
- have to know / be able to separate thoughts from feelings!!!
CBT - Homework methods employed
Why?
Evaluating these thoughts allows us to:
- gain some perspective
- find out what is exactly is happening
- its not just changing the way you feel!
- you are trying to understand that these maladaptive thoughts are driving the way you feel!
- stepping aside and challenging these thoughts!
What are the basic components of CBT?
What makes it successful?
- establishing a good therapeutic relationship
- educating the P about what they are going through
> model (CBT), disorder, therapy - setting goals collaboratively
- assessing symptoms objectively
- using evidence to try and guide treatment decisions
> personal spin to the work - structuring treatment sessions
- limiting treatment length
- setting and reviewing homework
> e.g. setting thought records - come back and discuss what they noted down
CBT - TREATMENT
- assessment
- provide rationale
- training in self-monitoring
- behavioural strategies
> monitor relationship between situation/action & mood
> applying new coping strategies to larger issues - identifying beliefs & biases
- evaluating and changing beliefs
- core beliefs & assumptions
- relapse prevention & termination
Basic Principles of CBT
Changing mood state
Change them using cognitive and behavioural strategies
- identifying / modifying automatic thoughts & core beliefs
- regulating routine
- minimising avoidance
Basic Principles of CBT
What is the emphasis?
Emphasis on the ‘HERE’ and ‘NOW’
Basic Principles of CBT
What are the preferences?
For concrete examples!
- start with specific situation - complete thought log etc
Basic Principles of CBT
Type of questioning?
- reliance on socratic questioning
- open-ended questions
Basic Principles of CBT
What kind of approach?
Empirical approach to test beliefs
- challenge thoughts that are not based on evidence
- cognitive restructuring
Basic Principles of CBT
What does it promote?
Promoting rapid symptom change
CBT - Behavioural Interventions
- breathing re-training
- relaxation
- behavioural activation
- interpersonal effectiveness training
- problem-solving skills
- exposure and response situation
- social skills training
- graded task assignment
CBT - Cognitive Interventions
- monitor automatic thoughts
- teach imagery techniques
- promote cognitive restructuring
- examine alternative evidence
- modify core beliefs
- generate rational alternatives
—> imaging yourself in situations and evaluate the thoughts etc
Why is CBT so popular?
- it is a core teaching in all doctorate clinical psychology programmes
- very clear principles & treatment approaches
- short term and structured nature of the treatment
- collaborative nature
> aids sense of control
> give people more control - more likely to want to actively participate in their treatment - great empirical support of findings
Efficacy of CBT
Butler et al (2006)
- review of meta-analyses
- 16 quantitative reviews; 332 clinical trials covering 16 different disorders or population, 9995 P’s
- high %’s for a range of disorders vs comparison groups
Efficacy of CBT
Hoffman et al (2012)
- efficacy of CBT - another review of meta-analyses
- only used about 100 studies
- strongest effect found for using CBT vs other treatments
- higher response rates for CBT vs other treatments
> fairly high but not too high for certain disorders
Criticisms of CBT
Too much of an mechanistic approach?
- needs to take / develop a more holistic approach
Have to update the model
- include findings from neuroscience, genetics & epigenetics into the model
- looking to see if there are any structural changes associated with CBT & if this knowledge can help us
There is limited evidence on the efficacy of components
