transdiagnostic approach

Question 1

limitations of disorder based therapies

Answer 1

• 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

Question 2

is classification valid but not always useful?

Answer 2

yes it is efficient but not necessry for treatment in psychology

Question 3

key factors are shared across disorders

distress irrespective of any particular diagnostic category

Answer 3

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?

Question 4

what are the criteria for transdiagnostic processes

Answer 4

Criteria for a transdiagnostic process
Strong methodology (e.g. valid measure; control group)
Present in ALL disorders & over 4 disorders

Question 5

what are the advantages of transdiagnosti approaches

Answer 5

generalise models across disorders
understand comorbidity
inform transdiagnostic treatments

Question 6

what are the transdiagnostic processes

Answer 6

attention
reasoning
behaviours
memory
thinking

Question 7

what is attention

Answer 7

Hypervigilance to external threat
Attentional avoidance of external threat
Hypervigilance to internal experiences

Question 8

what is memory

Answer 8

Recurrent intrusive memories
Selective memory
(Overgeneral memory)

Question 9

reasoning

Answer 9

Interpretational bias
Expectancy bias
Emotional reasoning

Question 10

thinking

Answer 10

Recurrent negative thinking
Metacognitive beliefs
(Thought suppression)

Question 11

behaviours

Answer 11

Avoidance
Safety-seeking behaviours
Experiential Avoidance

Question 12

what are the core processes

Answer 12

Anxiety , depression Standardised measures of thought suppression, worry & experiential avoidance
r = .5 to .7

Question 13

Separate processes vs core process in predicting distress in students & in chronic physical illness

Answer 13

worry thought suppression and experiential avoidance

Question 14

What does psychological distress and recovery involve?

Answer 14

• 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)

Question 15

what is control and why is it important

Answer 15

• Homeostasis is control; this is essential for life
• Now: temperature; balance; blood sugar
• Co-ordination & movement for any activity relies on control

Question 16

The historical context of Perceptual Control Theory

Answer 16

• 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)

Question 17

what is the negative feedback loop

Answer 17

percieve
compare
act
controlled variables
disturbance

Question 18

key principles of perceptual control theory

Answer 18

control
hierarchies
conflict
reorganisation

Question 19

what is control

Answer 19

Control is fundamental to life.We control our experiences. This is
achieved by a closed-loop process of perceive, compare and act

Question 20

what is hierarchies

Answer 20

Hierarchies - Control is organised in a hierarchy whereby long term goals and
principles are implemented by setting goals for lower level systems

Question 21

what is conflict

Answer 21

Conflict - When a person tries to control the same experience in opposing directions, conflict occurs and chronic conflict disrupts control

Question 22

what is reorganisation

Answer 22

Reorganisation - The properties of control systems are changed through a
trial-and-error learning process to reduce conflict and optimise control.
Reorganisation follows awareness.

Question 23

why?

Answer 23

Relates to individual values/ principles about the self, world and others

Question 24

what?

Answer 24

Experience being discussed

Question 25

how?

Answer 25

Relates to speciic control processes/ acions/ short term experiences

Question 26

Implications from PCT on what is effective about therapy…

Answer 26

* 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

Question 27

what maintains goal conflict

Answer 27

•“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’

Question 28

what is the core process

Answer 28

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

Question 29

shifting and sustaining awareness

Answer 29

* 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’

Question 30

what is Method of levels (MOL)

Answer 30

Transdiagnostic cognitive therapy from PCT

Question 31

what are the goals of MOL

Answer 31

* 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

Question 32

what body language focus on in MOL

Answer 32

indicators of background thoughts emphasising certain words smiling catch potential conflict not given a fixed number of sessions

Question 33

does method of levels work

Answer 33

significantl greater change in MOL group on anxiety and depression compared to TAU

Question 34

what is the hypothesis of Resolving goal conlict as a transdiagnostic process of change

Answer 34

Goal conflict maintains distress through loss of control when kept outside awareness by these processes

Question 35

preliminary findings of transdiagnostic process of change

Answer 35

• 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

Question 36

therapy manual

Answer 36

CBT across disorders managing blocks in therapy using PCT and method of levels

Question 37

is the transdiagnostic approach empirically supported

Answer 37

yes

Question 38

what does Overlaps between constructs indicate

Answer 38

Overlaps between constructs indicate that an integrative theoretical approach and therapy is required

Question 39

what does PCT provide

Answer 39

• 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

Question 40

what does PCT propose

Answer 40

• PCT proposes that mental health problems are chronic loss of control caused by unresolved goal conflict

Question 41

what is method of levels

Answer 41

Method of Levels designed to shift and sustain awareness to higher levels to resolve goal conflict