Wk 8 - Complex Problems Flashcards
What do we mean by complex problems in clinical contexts? (x5)
Interrelationship of various problems, that might be reinforcing each other
• Difficulties in where to intervene
Covers:
o Several presenting problems
o Longstanding difficulties that don’t fit any specific diagnosis but cause significant distress or impairment
o Personality disorders
Describe the biographical details of ‘Alex’ (complex problems case study) (x6)
32 year old woman Single, no children Lived in house with beloved dog and overseas students Worked fulltime in events management Catholic faith and principles Charity work
What precipitating events of ‘Alex’ (complex problems case study) (x7)
Extremely high arousal and distress
• Very difficult for her to articulate what was actually going on
History of being stalked over a 5 year period
Came to feel very unsafe
Reported to police
Culminating in sexual assault (2003)
Perpetrator a known and trusted neighbour
What was the main diagnosis of Alex’ (complex problems case study) (x8)
PTSD - from trauma outside normal experience Re-experiencing (intrusive images, nightmares) is common Physiological arousal (tension and anger, HR, shallow breathing, sleep disturbance, hypervigilance, GIT disturbance) (a) Hyper vigilance – constant scanning for threats, easily startled (b) Gastro-intestinal disturbances Avoidance (places, talking about it, intimate relationships) Sexual problems with ex-boyfriend leading to break-up – avoidance of sex Ran into perpetrator recently and vomited – trigger for getting help
What were additional problems of ‘Alex’ (complex problems case study) (x7)
Traits of histrionic personality
o Always immaculate presentation
o Excessive emotionality – like she was acting in her own drama
o Attention-seeking
o High need for approval
o Advanced social skills, persuasion
Alex and mother work together daily but Alex withholds information and attention from her mother
What was ‘Alex’s’ relationship history? (x4)
Series of short-term relationships with men
Very romantic idea of relationships – the perfect match is out there!
Avoidant style – wouldn’t sort things out in a relationship, just left
Relationship with John ended because of unmet emotional needs on both sides
What was the five-axis diagnosis of ‘Alex’
Axis I: 309.81 PTSD - chronic
Axis II: Traits of histrionic personality
Axis III: Loss of left lung function; history of serious airway problems, Crohn’s disease.
Axis IV: Relationship problems with mother, and (later) boyfriend
GAF: 55 at intake - general functioning still surprisingly going to work etc, but avoiding a lot of things, had little support
What does a just world view entail? (x2)
And what effect does trauma have on this? (x3)
Good things happen to good people and bad things happen to bad people – the stuff of fairy tales and nursery rhymes
Shatters such a view, so they do one of two things…
Over-accommodation
Assimilation
What is over-accommodation? (x1 plus x3 e.g. thoughts)
Changing your beliefs to accommodate the new experience, but over generalising
The world is an unfair, unsafe place
All men are out to harm me
I am damaged goods, nothing good will happen to me
What is assimilation? (x plus x1 e.g. thought process)
Changing the reality of her experience to fit her pre-existing beliefs
The world is a fair place, bad things happen to bad people and good things happen to good people, therefore, it didn’t happen. I must have imagined it; or I must have deserved it
What might be the target of early Stabilisation sessions? (from Alex and complex problems) (x6)
Look for key distortions (accommodation, assimilation), and look for ways to address them
Education about physiological arousal
Relaxation strategies – breathing, PMR
She had stopped walking much-loved dog through fear, so starting again was exposure therapy
Imagery of safe place – her Nana’s as a child
Focus on strengths and positives
What was Resick and Schtick’s Cognitive processing therapy developed for? (x1)
What does it entail? (x7)
Developed specifically for victims of rape, considered to be less personally confronting Gradual exposure and emotional processing using written and verbal narratives: o Impact statement o Self-blame or “undoing” o Safety o Trust o Power / control o Self esteem
Why did Dr Dingle choose Cognitive Processing Therapy over other PTSD treatments for ‘Alex’? (x3)
Such as eg Foa’s repeated exposure –
Due to high levels of physiological arousal and potential for overwhelming the client’s psychological resources.
Also help relationship functioning - linking sexual assault and impact on ability to relate to others, build trust, set reasonable boundaries, etc
How did Dr Dingle use Imagery and Music in ‘Alex’s’ treatment? (x3 and x2)
Image of stalker’s face frequently intrusive
o Used imagery processing (eg Hackman)
o Created image of a small rodent that she could kick away with her sturdy boots
Use of theme songs to improve mood and self confidence, eg:
o “All Fired Up” – Pat Benetar
What are three types of therapy that fall under the banner of ‘Third wave’ of cognitive therapies?
Mindfulness – a Buddhist philosophy
ACT – Acceptance & Commitment Therapy
DBT – dialectical behavior therapy also includes mindfulness
What is the central tenet of the Third wave of cognitive therapies?
Which is based on realisation that… (x2)
‘thoughts are not facts’
Identifying and challenging your thoughts of cognitive behavioural therapy – some have argued that such a focus on them can actually worsen them
How did Kabat-Zinn define mindfulness? (x1)
Which he introduced into therapy because… (x2)
Paying attention in a particular way: on purpose, in the present moment and non-judgmentally”
Ran groups for cancer, HIV, chronic pain etc,
Struggling to use cognitive approach of finding evidence that things were going to get better – often it wasn’t
What are mindfulness skills according to Kabat-Zinn? (x3)
Which require… (x1)
Cognitive delusion: Recognising that thoughts are not “truth” - detaching from them
Contact with present moment: Awareness and openness to the now (e.g. Raisin exercise)
The observing self: The transcendental self - fly on the wall, eg seeing that someone is angry and wondering about it rather than reacting
Daily practice rather than ‘10 sessions and you’re done’
What are the uses of the Acceptance technique of ‘making room’? (x3)
And it involves.. (x2)
Good for grief, anxiety, pain – things where our tendency is to fight them, get rid of them, as they’re painful. We want to avoid them
Rather than just I’m in pain all the time, analyse it to describe it as a thing
And then try to find a way to embrace it, give it some room in your life
Describe the Acceptance exercise from Walser and Westrup’s ‘Mindful Couple’ (x4)
Imagine partner comes to door with flowers, smiling, which you happily accept
Then they give you a list of all their positive qualities which you read, acknowledging the ones that are most meaningful to you
Then they give you list of their foibles and faults, and you do the same
When you’re done, you look at them, open the door and invite them in
What does research show that mindfulness is effective for? (x9)
Anxiety disorders Depression - relapse prevention Stress reduction Pain Cancer Heart disease Hot flushes HIV, Arthritis
What is Acceptance? (x2)
Not merely tolerance –
Rather it is the active non judgemental embracing of experience in the here and now
What are the goals of ACT? (x3)
To increase psychological flexibility – not fixated/prepared to see another’s perspective, expanding toolkit for understanding experiences
Counter experiential avoidance – trying to avoid/get rid of difficult internal sensations
Practice committed action - behaving in congruence with your values
What are six core processes in ACT?
Acceptance Cognitive defusion Being in the present Self as context – being the observer Clarifying values Committed action
What do we mean by ‘cognitive fusion’ in ACT? (x1)
Plus e.g. of defusion (x2)
Notion that our thoughts are “truth”
e.g. “I’m too depressed to go to work”, becomes
“I’m having a thought that I’m too depressed to go to work”
What do we mean by ‘experiential avoidance’ in ACT? (x2)
Unwillingness to stay in contact with internal experiences (thoughts, emotions, images),
That underlies unhealthy behaviours such as substance abuse, eating disorders, self harm.
What areas might you consider when ‘clarifying values’ in ACT? (10)
Through what two methods?
- Family relations
- Couples / intimate relations
- Parenting
- Friendships
- Career / employment
- Education / personal growth
- Recreation / leisure
- Spirituality
- Environment / community life
- Health / physical wellbeing
Worksheets, or just in conversations
What disorders is ACT supported for? (x6)
- Anxiety and depression
- Psychosis
- Chronic pain
- Phobias, worry, social anxiety
- Intellectual impairment
- Autism
Why did Marsha Linehan develop Dialectical behaviour therapy? (x2)
As a treatment for parasuicidal women with Borderline Personality Disorder
Following teen hospitalisation for her own
What is a dialectic? (x1)
And what is the key dialectic in DBT? (2)
Method of argument or dialogue in which opposing views try to persuade each other
Figuring out what we need to change, and the needs acceptance
What is the biosocial theory of Borderline Personality disorder? (x4)
Biological: dysfunction of emotion regulation system (genetics, foetal development, early trauma, in utero drugs)
Environmental: invalidating environment - shutdown by caregivers
Leads to pattern of self-invalidation, difficulty identifying emotion, extreme patterns of emotion expression/dysregulation
• Issues of extreme behaviour to get attention
What are the four stages of treatment in DBT?
1: safety and behavioural control
2: appropriate emotion – express primary rather than secondary
3: increase experience of normal (un)happiness, improve relationships and self-esteem
4: promotion of connectedness and freedom (transcendence)
Can be long-term, 1 yr+…
What is involved in behavioural analysis in DBT? (x9)
Diary of parasuicidal behaviour - common/most serious presenting problem
Chain analysis of behaviour (acting out get attention)
Hypotheses about factors controlling behaviour
Solution analysis – alternative ways of managing at each stage
• Prompting event
• Thoughts and emotions
• Problem behaviour
• Consequences
• Reinforcement
What is the function of behavioural analysis in DBT? (x2)
Contingency management – the analysis of the self harm behaviour is aversive, acts as a mild punisher
Exposure
What four skills modules are involved in DBT?
Mindfulness
Distress tolerance
Emotion regulation
Interpersonal effectiveness
What role does mindfulness play in DBT? (x3)
Trying to encourage use of the wise mind –
Taken from concept of three minds (reasonable, emotional and wise – which is calm and can think careful about situationally appropriate behaviour)
What is the focus of ‘distress tolerance’ in DBT? (x1 plus e.g. x2)
What to do in the moment that you feel like harming, doing the impulsive behaviour
Crisis survival skills = staying safe until painful emotion passes and problem solving can be done;
Acceptance skills = facing reality of ones life circumstances
What is involved in ‘interpersonal effectiveness’ module of DBT? (x4)
Engage support, communicate needs, without the anger or manipulation
Managing conflict more effectively;
Expressing primary emotions assertively;
Eliciting validating responses from sig others
What is involved in ‘emotion regulation’ module of DBT? (x4)
Awareness and labelling of primary emotion
Mindful experiencing of primary emotion
Increasing positive emotions
Taking opposite action to the emotion
What disorders is DBT supported for? (x5)
BPD (plus with drug dependence) Chronically suicidal adults Suicidal adolescents Distressed couples Binge eating disorder
