transdiagnostic approach Flashcards
limitations of disorder based therapies
- There are dozens of different disorders in the population
- Are we really going to train therapists different models for different psychiatric disorders?
- Average no. sessions attended is around five (Hansen et al. 2002)
- Greatest treatment gains in the first session (Lambert et al. 2001)
- 30-80% of patients have comorbid disorders
- Standardised diagnosis is not conducted (c.90mins)
Therefore we need a universal flexible therapy that can be started early on
is classification valid but not always useful?
yes it is efficient but not necessry for treatment in psychology
key factors are shared across disorders
distress irrespective of any particular diagnostic category
Pivotal papers: e.g. Ingram (1990); Persons (1991); Hayes et al. (1996)
‘Transdiagnostic’ CBT for Eating Disorders (Fairburn, Shafran & Cooper, 2003)
Biology (e.g. COMT gene) - OCD, schizophrenia, bipolar disorder, anorexia nervosa, phobias
Social Factors (e.g. Expressed Emotion) : Schizophrenia, mood disorders, anxiety disorders, eating disorders
So, what is the evidence that the ‘mechanisms’ maintaining disorders might be shared?
what are the criteria for transdiagnostic processes
Criteria for a transdiagnostic process
Strong methodology (e.g. valid measure; control group)
Present in ALL disorders & over 4 disorders
what are the advantages of transdiagnosti approaches
generalise models across disorders
understand comorbidity
inform transdiagnostic treatments
what are the transdiagnostic processes
attention reasoning behaviours memory thinking
what is attention
Hypervigilance to external threat
Attentional avoidance of external threat
Hypervigilance to internal experiences
what is memory
Recurrent intrusive memories
Selective memory
(Overgeneral memory)
reasoning
Interpretational bias
Expectancy bias
Emotional reasoning
thinking
Recurrent negative thinking
Metacognitive beliefs
(Thought suppression)
behaviours
Avoidance
Safety-seeking behaviours
Experiential Avoidance
what are the core processes
Anxiety , depression Standardised measures of thought suppression, worry & experiential avoidance
r = .5 to .7
Separate processes vs core process in predicting distress in students & in chronic physical illness
worry thought suppression and experiential avoidance
What does psychological distress and recovery involve?
- Qualitative Interviews & Analysis
- Themes of loss of control at the ‘rock bottom’ & regaining control as the process of recovery •Fits with wider literature
- Natural recovery across disorders (Higginson & Mansell, 2008)
- Primary care service (McEvoy et al., 2012)
- Bipolar disorder (Mansell et al., 2010)
- Eating problems (Alsawy & Mansell, 2013)
- Use of art in recovery (Stevenson-Taylor & Mansell, 2012)
what is control and why is it important
- Homeostasis is control; this is essential for life
- Now: temperature; balance; blood sugar
- Co-ordination & movement for any activity relies on control
The historical context of Perceptual Control Theory
- Fits with the teleological approach of early psychology (e.g. William James, John Dewey)
- Fits with importance of unconscious conlict (Freud, Horney)
- Powers was a control system engineer who developed the theory through the 1950s & 60s
- Encountered cybernetics (e.g. Wiener; Ashby)
- Inluenced William Glasser’s Reality Therapy; Klaus Grawe’s Psychological Therapy; now inluencing the development of CBT (Mansell, 2005)
what is the negative feedback loop
percieve compare act controlled variables disturbance
key principles of perceptual control theory
control
hierarchies
conflict
reorganisation
what is control
Control is fundamental to life.We control our experiences. This is
achieved by a closed-loop process of perceive, compare and act
what is hierarchies
Hierarchies - Control is organised in a hierarchy whereby long term goals and
principles are implemented by setting goals for lower level systems
what is conflict
Conflict - When a person tries to control the same experience in opposing directions, conflict occurs and chronic conflict disrupts control
what is reorganisation
Reorganisation - The properties of control systems are changed through a
trial-and-error learning process to reduce conflict and optimise control.
Reorganisation follows awareness.
why?
Relates to individual values/ principles about the self, world and others
what?
Experience being discussed
how?
Relates to speciic control processes/ acions/ short term experiences
Implications from PCT on what is effective about therapy…
- Solutions will be successful when both sides of the conflict are accommodated
- Solutions will be unpredictable and novel
- Time taken to resolve a conflict will vary
- Logical problem solving might be ineffective
- Advice will be of limited value
- “Resistant” clients might be operating from one side of a conflict
- When therapy is less than effective a conflict formulation might be useful
what maintains goal conflict
•“Controlling an experience without regard to, or an awareness of, the important personal goals that it interferes with” – this creates & maintains goal conflict
Not just a form of avoidance (e.g. pursuing drugs; ‘hyping self up’; avoidance can be helpful, e.g. real danger; in work settings)
• It is interference with people’s goals that leads to the chronic disruption in
functioning - the key criterion of a psychological ‘disorder’
what is the core process
It is the lack of awareness of goal conlict that is the core process…
•Person controls an experience despite the conflict it causes with control of ‘higher level’ experiences
shifting and sustaining awareness
- Enable change in systems that regulate inflexible processes; ‘metacognitive’
- Help shift awareness to long term goals, values & broader perspectives
• e.g. realising that a good working life is more important than not feeling anxious all the time &
therefore experiment with ‘exposure’ to anxiety
• e.g. exploring conflict: the need to ‘speak up at work’ vs. the need ‘not to be rejected’ - in the long term to‘be accepted for who I am’
what is Method of levels (MOL)
Transdiagnostic cognitive therapy from PCT
what are the goals of MOL
- Every therapist statement is an open question
- GOAL ONE: To help the client talk about the problem
- GOAL TWO: To ask about present moment disruptions
- focuses on the process of control of perception
- catches possible conflict
- identifies higher level goals
- Iterative procedure; open-ended
- Promising findings in several pragmatic case series in primary care
what body language focus on in MOL
indicators of background thoughts
emphasising certain words smiling catch potential conflict
not given a fixed number of sessions
does method of levels work
significantl greater change in MOL group on anxiety and depression compared to TAU
what is the hypothesis of Resolving goal conlict as a transdiagnostic process of change
Goal conflict maintains distress through loss of control when kept outside awareness by these processes
preliminary findings of transdiagnostic process of change
• Writing about goal conflict reduces distress about the conflict (Kelly et al., 2011)
• Interactive computer therapist (Gafney et al., 2014)
• Searches participant text for key terms
• Asks questions to sustain attention on them
• Awareness of conlict correlated with reduction in distress & mediated the effect of positive expectancy
emulating same questions in methods of levels and asking question to help them notice their conflicts and sustain awareness of it
therapy manual
CBT across disorders
managing blocks in therapy
using PCT and method of levels
is the transdiagnostic approach empirically supported
yes
what does Overlaps between constructs indicate
Overlaps between constructs indicate that an integrative theoretical approach and therapy is required
what does PCT provide
• PCT provides an alternative psychological perspective – ‘behaviour is the control of perception’
Control at heart of health. Unresolved goal conflict undermines control
Perceptual control theory
what does PCT propose
• PCT proposes that mental health problems are chronic loss of control caused by unresolved goal conflict
what is method of levels
Method of Levels designed to shift and sustain awareness to higher levels to resolve goal conflict
