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Ovid: Oxford Handbook of Psychiatry

Editors: Semple, David; Smyth, Roger; Burns, Jonathan; Darjee, Rajan; McIntosh, Andrew Title: Oxford Handbook of Psychiatry, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 18 – Psychotherapy Chapter 18 Psychotherapy P.764
Introduction Psychotherapy is the ‘talking cure’—the attempt to alter abnormal thinking and behaviour by a dialogue taking place within a relationship. Psychotherapeutic methods are used both to conceptualise abnormal mental states (to understand why symptoms have developed in this patient at this particular time) and to treat the attendant disorders. There are a variety of different psychotherapeutic methods, each usually initially associated with a single individual or centre. In its broadest sense—of achieving understanding of symptoms and effecting their improvement by means of a therapeutic relationship—psychotherapy is at the heart of all medical and therefore all psychiatric treatment. Types of psychotherapy

  • Supportive psychotherapy Aims to offer practical and emotional support, opportunity for ventilation of emotions, and guided, problem-solving discussion. Used where fundamental behavioural change is not aimed for, or where patient factors (e.g. learning difficulty, psychotic illness) preclude exploratory therapies. Examples include counselling, general psychiatric follow-up.
  • Exploratory psychotherapy Aims to effect change in the individual’s abnormal thinking and behaviour by exploration of underlying causes.
    • Dynamic therapies Based on psychoanalytic theory. Focus of clinical attention is childhood experience and exploration of the unconscious mind.
    • Cognitive/behavioural therapies Based on learning theory and cognitive theory. Focus of clinical attention is the ‘here and now’: current behaviours and thoughts, and their modification.

Common factors to different psychotherapies

  • A theory of illness or symptom development.
  • Empirical or case-based evidence to support this theory.
  • A rationale for treatment.
  • Prescribed roles for the therapist and patient.
  • A form of structured therapy—sometimes in the form of a manual.
  • Takes place in a setting recognised as a ‘place of healing’.

Psychotherapeutic training As a psychiatric trainee you will be expected to gain experience in at least one type of psychotherapy during your training. This will usually be via supervised long and short case experience. You may also undertake a period of basic or higher training in a psychotherapeutic centre during one of your clinical attachments. Following suitable personal and tutorial based training in the method, you will take on a case under the supervision of an individual with the requisite experience. It is only through the process of therapy and supervision that you will really understand psychotherapeutic techniques. These notes on general concepts and specific psychotherapies aim to familiarise you with concepts, guide your referrals, and assist you in explaining the process to patients. P.765
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Assessment for psychotherapy Psychotherapeutic methods can be useful in the treatment of mild to moderate depressive illness, neurotic disorders, behavioural disorders, and personality disorders. Specific therapies may have a place in the management of learning disability, sexual problems, substance misuse, and chronic psychotic symptoms. They are generally contraindicated for acute psychosis, severe depressive illness, dementia/delirium, and conditions where there is acute suicide risk. Selection criteria for psychotherapy

  • ‘Psychological-mindedness’ The ability to understand problems in psychological terms.
  • Motivation for insight and change Includes the ability to form a ‘therapeutic alliance’, which requires a degree of introspectiveness, average intelligence, and verbal fluency.
  • Adequate ‘ego strength’ Includes the ability to sustain feelings and fantasies without impulsively acting upon them, being overwhelmed by anxiety, or losing the capacity to talk rationally. The individual should be capable of maintaining a therapeutic alliance and there should be no impairment of ‘ego boundaries’ due to psychosis or severe depression.
  • Able to form and sustain relationships Where there is inability to enter into trusting relationships, (e.g. in paranoid personality disorder) or where there is inability to maintain relationship boundaries (e.g. in borderline personality disorder), this may preclude exploratory methods.
  • Able to tolerate change and a degree of frustration As with any potentially powerful treatment, psychotherapy has the potential to exacerbate symptoms, particularly as maladaptive coping mechanisms are examined and changed.

Selection of psychotherapeutic method

  • Local availability In practice, often the main determinant of therapy choice is local availability and the practical availability determined by the length of the waiting list. The waiting times associated with most forms of therapy should encourage all practitioners to exercise care in patient referral.
  • Practitioner experience In some cases the treating doctor will take on therapy themselves and utilize the method with which they are familiar.
  • Illness factors The exact suitability of each of the therapy methods has yet to be clearly established. Nonetheless, some therapies are indicated for particular disorders, (e.g. behaviour therapy for simple phobias, CBT for anorexia nervosa).
  • Patient choice Patients may express a preference for a particular therapeutic model because of previous positive experience or having read or been told about the approach of different methods. A method which ‘makes sense’ to the patient given their understanding of their symptoms is desirable.

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Counselling Counselling may be thought of as a method of relieving distress undertaken by means of a dialogue between two people. The aim is to help the client or patient find their own solutions to problems, while being supported to do so and being guided by appropriate advice. In Western countries over the last fifty years, counselling has emerged as a profession in its own right and individual forms of specific counselling have been developed. In its more general sense—helping others by the provision of advice, non-judgemental reflection, and emotional support—counselling takes place all over the world in the guise of family members, priests, tutors, teachers, etc. Counselling skills are integral to the practice of medicine, particularly in primary care and psychiatry, where counselling techniques are useful in history taking, assessing and ensuring compliance, etc. Counselling should not be thought of as ‘cut-down’ or ‘half-price’ psychotherapy. There is clearly overlap in the methods and skills of a psychotherapist and a counsellor. However, the decision to use counselling as a specific treatment, (e.g. for postnatal depression) should be made after considering both the disorder and the patient. There are a variety of counselling services in the voluntary and private sectors, some directed towards specific problems and some more general. Rationale Behaviour and emotional life are shaped by previous experience, current environment, and the relationships the individual has. Many life problems can be viewed as arising from resolvable difficulties in one of these three areas, rather than as an ‘illness’. People have a tendency towards positive change and fulfilment which can be retarded by ‘life problems’. A collaborative relationship with a counsellor (however defined) is one method of addressing these issues. This relationship will proceed according to agreed rules, towards a goal, and will be based on developing the client’s strengths. Techniques

  • Information giving Key to all psychiatric treatment and psychotherapeutic work. Information should be provided in a form the patient can understand and information giving should not be a ‘one off’ but should continue throughout counselling.
  • Client-focused discussion The client should ‘lead’ the sessions particularly beyond the early information gathering sessions. Time constraints may hinder this.
  • Problem solving A variety of techniques, particularly those borrowed from cognitive behavioural therapy are employed here. The basic goal is to use the session time to explore current and potential future problems and to help the client consider the optimum solution.

Different types of counselling

  • Information sharing/discussion In some contexts is also called psychoeducation. Aim is to properly inform a client prior to them making their own decision. Techniques of guided learning, providing verbal and written information, collaborative enquiry (cf. CBT).
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  • Crisis management Views crisis as stressor providing both risk and opportunity to change/learn/develop. Short term, immediately follows trauma (first few weeks). Facilitates adaptive and normal emotional responses, discourages maladaptive responses. Focus on end-point of intervention. Alternative to hospital admission in some cases. Should have access to alternative treatments if necessary.
  • Problem-based counselling Directed towards a specific primary problem, (e.g. drug misuse, CSA). Counsellor may or may not have had similar experiences themselves.
  • Risk counselling Used to guide an informed decision (e.g. pre-natal interventions, genetic counselling). Differentiated from other forms of counselling by the fact that the counsellor is clearly ‘the expert’ and has access to specialist information. Nonetheless, the basic goal, of enabling the patient to come to their own decision, with appropriate information and support, remains the same.

Indications Absolute advice limited by lack of comparative trials and tendency for local availability of services to be the main factor in the decision to use counselling methods. Clinical usefulness in:

  • Adjustment disorder.
  • Mild depressive illness.
  • Normal and pathological grief.
  • Sequelae of childhood sexual abuse.
  • After other forms of trauma (e.g. rape, accidents).
  • Postnatal depression.
  • Pregnancy loss and stillbirth.
  • Drug and alcohol problems.
  • Reaction to chronic medical conditions.
  • Prior to decision such as undergoing genetic testing or HIV testing.

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A brief history of Sigmund Freud Freud remains far and away the world’s best-known psychiatrist and his image, of a scholarly, bearded man sitting behind a distressed patient lying on a couch, is many lay-people’s archetype for our profession. He made a huge contribution to our understanding of the mind, but many of his ideas are now so much a part of our general view of the world that it is easy to overlook the breakthroughs they originally were. He was born in 1856 in Moravia (now part of the Czech republic, but then part of the Austro-Hungarian Empire). He moved to Vienna when he was a child and lived there until his last year. On entering medical training he was influenced by scientific empiricism—the belief that through careful observation the un-understandable could be understood. On qualification he began laboratory work on the physiology of the nervous system under Brücke, later entering clinical medical practice after his marriage in 1882. He chose neurology as his specialty and received a grant to study at the Salpétrière in Paris where he was exposed to the ideas of Charcot who interested Freud in the study of hysteria and the use of hypnosis. In Paris with Charcot, and later in Nancy with Liébault, he studied the behaviour of hysterical patients under hypnosis and developed his ideas of the unconscious mind and its role in normal and disordered behaviour. Returning to Vienna, Freud began collaboration with Josef Breuer on the study of hysteria. The subsequent development of psychoanalysis was prompted by the case of Anna O., treated by Breuer between 1880 and 1882. This patient, a 21-year-old woman (real name Bertha Pappenheim) presented with a range of hysterical symptoms including paralysis, visual loss, cough, and abrupt personality change. These symptoms had developed while her father was terminally ill. Breuer observed that her symptoms resolved during hypnotic trances. Breuer also noted that not only did the symptoms recur after the sessions ended, but that after he terminated the treatment relationship she suffered a full-blown relapse. Breuer wrote up the case after discussing it with his younger colleague. Later they published Studies in Hysteria, detailing their ideas on the aetiology and treatment of hysterical symptoms. This book postulated that trauma is unacceptable to the patient and hence repressed from conscious memory. This repression produces an increase in ‘nervous excitation’—which is expressed eventually as hysteria—with a conscious remnant, often in a disguised form, which can be accessed and resolved during hypnosis. Freud explored these ideas during his clinical practice in the 1890s, using a variety of methods to uncover the repressed memories. Later he developed the technique of free association, where the patient is encouraged to say whatever comes to mind. He noted that some patients developed powerful feelings towards him and called this phenomenon transference. Experience in the 1890s led Freud to develop the ideas of repression of unacceptable memories and their expression as hysterical symptoms. The initial memory was generally of a sexual nature. At first Freud thought this was a real assault, but later realised that in the majority of cases the patients were describing a sexualised fantasy towards parental figures. Freud described these ideas in his most famous book, The Interpretation of Dreams, published in 1900. It described the basis of his psychoanalytic technique including analysis of the content of dreams, descriptions of P.771
defence mechanisms, and his topographical model of the mind. Freud’s early insights tended to come directly from clinical experience, particularly patients with hysteria. His later ideas were more theoretical and related to developing a complete understanding of the normal and abnormal development of mind through psychoanalytical ideas. His drive theory postulated the existence of basic drives, which included the libido, the sexual drive, and the eros and thanatos (the drives towards life and death). He described the pleasure principle, the drive to avoid pain and experience pleasure, and its modification through the reality principle. In 1905 he published Three essays on the Theory of Sexuality, describing his theories regarding childhood development including the ideas of developmental phases and the Oedipal and Electra complexes and their relationship with the development of adult neuroses. The Ego and the Id, published in 1923, saw the replacement of the topographical with the structural model of the mind. He described his theories of ego psychology and the production of anxiety symptoms in Inhibitions, Symptoms and Anxiety in 1926. Although he recognised the importance of unconscious defences in response to anxiety, the first systematic account of these mechanisms was written by Freud’s daughter Anna in The Ego and the Mechanisms of Defence in 1936. Freud’s repeated revision of his own theories was mirrored by repeated disagreements and splits in the psychotherapeutic movement and the formation of separate psychotherapeutic ‘schools’, usually strongly associated with one charismatic individual. Freud died from cancer in England in 1939 after fleeing Vienna following the rise to power of the Nazis. His daughter Anna continued to refine and publicise her father’s work. Jung Expanded drive theory to include drives other than sexual. Ideas of ‘collective unconscious’ and personality archetypes. Ideas of extroversion and introversion. Klein Theories of childhood development including primitive defence mechanisms such as ‘splitting’. Methods of play therapy. Winnicott Object relations theory—gratification through relationships as well as through satisfaction of desires. Described transitional objects and the idea of the ‘Good enough mother’. Erikson Described alternative model of psychosocial development based on the crises at each developmental stage. Rogers Client-centred therapy. Importance of therapeutic attributes of genuineness, unconditional positive regard, and accurate empathy. Berne Transactional analysis. Examination of ‘games’ and ‘scripts’ which characterise relationships. P.772
Basic psychoanalytic theory (1) Freudian theories of symptom development ‘Psychic abscess’ theory In the treatment of his early patients, described in Studies on Hysteria, Freud conceived of hysterical symptoms as arising as an indirect result of a previous traumatic event in the patient’s life. The memory of this trauma was painful and the emotions associated with its recall gave rise to unacceptable contradictions in the patient’s beliefs about themselves. They were therefore repressed from consciousness. Although the memories were not recalled directly, the powerful associated emotions were expressed as hysterical symptoms, sometimes with symbolic connection to the initial traumatic event. The hysterical symptoms could be treated (and the ‘psychic abscess lanced’) by forcing the memories into consciousness by abreaction. Topographical model of the mind Described in The interpretation of dreams, later superseded by the structural model. In this model the mind consists of the unconscious, the preconscious, and the conscious. Only those ideas and memories in the conscious mind are within awareness. The preconscious performs a ‘censorship’ function by examining unconscious ideas and memories and repressing those which are unacceptable. The unconscious mind acts according to the ‘pleasure principle’—the avoidance of pain and the seeking of gratification. This is modified by the ‘reality principle’ of the conscious mind. Structural model of the mind Proposed in 1923. It consisted of the Id, the Ego, and the Superego. The Id pursues its own desires and is heedless of external reality or moral constraints. A new born baby’s mind is conceived as all Id. The Ego emerges during infancy and is the personality which moderates the desires of the Id. The Superego (the ‘conscience’) is the internalisation of the morals and strictures of society, which provides judgements on what behaviours are acceptable and which are ‘bad’. When the Ego is unable to successfully moderate between the Id and Superego it may defend the individual’s sense of self by repressing the impulse to the unconscious where its presence may produce disturbance. Ego defence mechanisms Freud conceived the idea of the repression of unacceptable thoughts from conscious awareness. Subsequently a number of other ‘defence mechanisms’ were described, viewed as developing to prevent conflict between the conscious mind and the unconscious desires. Repression Preventing unacceptable aspects of internal reality coming to conscious attention by unconscious ‘forgetting’ of the painful memory or unacceptable impulse. (e.g. in adult life, no longer being able to recall episodes of childhood sexual abuse) The associated emotional reaction may remain in the conscious mind but divorced from its accompanying idea. Regression Responding to emotional stresses by reverting to a level of functioning of a previous maturational point. P.773
Denial Preventing unacceptable aspects of external reality coming to conscious attention by refusal to consciously acknowledge events or truths which are obvious to other people. Distortion Similar to denial. Dealing with a reshaped version of external reality rather than the true version. Projection Attributing one’s own unacceptable ideas and impulses to another person. Projective identification Similar to projection. Here the individual attributes his negative response to another as a justifiable response to the attitudes he perceives them as having. Isolation/intellectualisation Dealing with emotion-laden memories or ideas by considering them in an logical manner, divorced from emotion. Reaction formation The expression externally of attitudes and behaviours which are the opposite of the unacceptable internal impulses. Displacement Transferring the emotional response to a particular person, event, or situation to another where it doesn’t belong but which carries less emotional ‘risk’. Rationalisation Justifying behaviour or feelings with a plausible explanation after the event, rather than examining their underlying, consciously unacceptable explanation. Undoing Performing an action which has the effect of unconsciously ‘cancelling out’ an unacceptable internal impulse. The action may have an obvious symbolism related to the internal impulse. Splitting Separating the good and bad aspects of a person or situation in one’s mind in order to avoid the ambivalence felt towards the whole person. Turning against the self Unacceptable feelings of internal hostility or aggression towards others are expressed in harm to oneself. Compensation The conscious development of abilities in response to a deficit. Sublimation Regarded as the most ‘healthy’ of the defence mechanisms. The external expression of unacceptable internal impulses in socially acceptable ways. Transference reactions Transference The development, in the patient, of feelings and patterns of behaviour towards the therapist which unconsciously partly recapitulate earlier relationships in their lives. Counter-transference Describes the equivalent reaction in the therapist towards the patient. The examination of the transference and counter-transference is a central part of dynamic psychotherapy and guides diagnostic formulation and the exploration of the patient’s neurosis in therapy. P.774
Basic psychoanalytic theory (2) Freudian theory of psychosexual development Freud believed that the psychological conflicts which produced morbidity arose during infancy and childhood. He developed a theory which attempted to explain the development of sexuality in children. He visualised four phases, characterised by particular satisfactions and conflicts. Inability to resolve conflicts at a particular stage would lead to subsequent adult problems.

  • Oral stage Birth to ~18 months. Pleasure comes from suckling and investigation of objects by placing them in the mouth.
  • Anal stage 18 months to 3 years. Pleasure comes from anal sensations and the ability to withhold and to appropriately produce faeces.
  • Phallic stage 3 to 6 years. Pleasure comes from manipulation of the phallus. This behaviour is not socially sanctioned and may be associated with shame and concealment. In addition, Freud postulated a range of anxieties related to the child’s evolving ideas about itself and about gender and sexuality, including the Oedipus and Electra complexes.
    • Oedipus complex The young boy focuses his erotic attraction towards his mother and develops resentment towards his father who blocks his total possession of her. Because of his hostility towards his father and following his observation of the difference between males and females, he imagines his father may take revenge by castrating him (castration anxiety). This anxiety leads to repression or resolution of the desire for exclusivity in maternal relations and the child enters the latent phase.
    • Electra complex In young girls there is also an erotic desire for the mother and initial hostility towards the father as a rival. Due to her absence of a penis there is penis envy which becomes expressed as hostility towards the mother who she feels has handicapped her in her desires. This envy leads to an acceptance that she cannot compete with her father due to her lack of a penis and so the desire is transformed into a desire to have a baby as a penis substitute. The young girl then develops an Oedipal attachment towards her father as a potential father for this baby before again repressing these desires and entering the latent phase. Lack of the spur of castration anxiety leads to the conflict being harder to resolve in females than males.
  • Latency phase 6 years until puberty. Period of relative quiescence of sexual thoughts between the resolution of the Oedipus/Electra complex and the awaking of adult sexuality.
  • Genital phase Period of mature adult sexuality. During this period, improper resolution of previous phases may be manifest in symbolic ways.

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The story of Oedipus (Sophocles -430 B.C.) King Laius of Thebes is told by the oracle at Delphi that his son will kill him and marry his wife. When his wife Jocasta gives birth to a boy, Oedipus, he orders a slave to abandon the child on a mountain. The slave takes pity on the child and, instead of leaving him to die, gives him to a shepherd, who brings him to the King of Corinth who is childless. Oedipus grows up thinking that Polibus, King of Corinth is his father. As a youth, Oedipus visits the oracle at Delphi and is told that he will grow up to kill his father and marry his mother. At this, Oedipus vows never to return to Corinth and sets out for Thebes instead. On a narrow part of the road he meets an old man in a chariot who angrily orders him aside and strikes him with a spear. Oedipus seizes the spear to defend himself and strikes the old man on the head, killing him. The man is Laius, King of Thebes, his real father. Approaching Thebes, Oedipus meets the Sphinx which is terrorising the city. The monster is stopping all passers-by and challenging them with its riddle; those who fail to answer the riddle are devoured. Oedipus solves the riddle of the Sphinx and the monster jumps to its death. He enters the city as a hero. He is told that the king has been murdered and is offered the throne, together with the hand of Jocasta in marriage. Oedipus is a wise and successful king and Jocasta bears him two sons and two daughters. Many years later Thebes is afflicted by a terrible plague. The people appeal to Oedipus to save them and he sends his brother-in-law to the oracle at Delphi for advice. The oracle states that the plague will abate when the murderer of Laius is banished. Oedipus promises to bring the murderer to justice and forbids the people of Thebes from offering him any shelter. Oedipus asks the prophet Teiresias to help him discover the killer’s identity. Teiresias tries to dissuade him from pursuing the matter but the king persists, eventually accusing the prophet of being a fraud. Teiresias them angrily tells him that before nightfall he will find himself ‘both a brother and a father to his children’. The king is bewildered and Jocasta tries to comfort him by telling him about the prophecy given to Laius—it was prophesied that he would be killed by his son, when in fact his son had died as an infant and he had been killed by bandits—hence prophecies could not be trusted. This story only increases Oedipus’s worry and he suspects that he murdered Laius but does not yet realise that Laius was his father. A messenger arrives to inform him of the death of the King of Corinth. The messenger also reveals that Oedipus was adopted. He begins to suspect that he is the son of Laius and continues to investigate, ignoring the pleas of Jocasta who has already realised the whole truth. Eventually he finds the shepherd who took him to the household of the King of Corinth and the full truth is revealed. At this point he hears anguished cries coming from the palace and rushes to his apartments. Oedipus breaks down the door of the royal bedchamber to find the queen, his wife and mother, has hung herself. He seizes her dress pin and gouges out his eyes so as not to have to look at the atrocity he has unwittingly committed. He enters into exile, having failed to avoid the fate laid out for him. P.776
Dynamic psychotherapy A method of therapy derived from the theories and practice of Sigmund Freud. Psychoanalytic theories have been repeatedly refined and reviewed over the last century, however the principles of dynamic psychotherapy remain similar—the gradual exploration with the patient of thoughts and conflicts not previously directly accessible to the conscious mind. How illness is viewed Overt symptoms are merely the external expression of underlying psychic abnormality. Symptoms continue, despite the suffering they cause to the individual because of what Freud called primary gain. This is the benefit to the individual of not having unacceptable ideas in the conscious mind. Rationale Traumatic experiences, particularly those in early life, give rise to psychological conflict. The greater part of mental activity is unconscious and the conscious mind is protected from the experience of this conflict by in-built defences, designed to decrease ‘unpleasure’ and to diminish anxiety. These defences are developmentally appropriate but their continuation into adult life results in either psychological symptoms or in a diminished ability for personal growth and fulfilment. Conflict can be examined with regard to the anxiety itself, the defence, or the underlying wish or memory. The individual’s previous family and personal relationships will have symbolic meaning and be charged with powerful emotions. Representations of these relationships will emerge during therapy and provide a route towards understanding and change. Techniques

  • Free association The process of free association is the main route for the exploration of the unconscious. The ‘fundamental rule’ of psychoanalysis is that the patient agrees to reveal everything which comes to mind during free association, no matter how embarrassing or socially unacceptable (i.e. ‘speaking without self-censorship’). Areas where free association ‘breaks down’ and areas of resistance to further associative thought suggest important areas to be explored at future sessions.
  • Examination of dreams Dreams are viewed as being formed by an admixture of daytime memories, nocturnal stimuli, and representations of unconscious desires. This admixture, the ‘latent dream’, is converted to the ‘manifest dream’ by ‘dream work’—a process of symbolisation and elaboration. This process can be consciously unravelled with a therapist to reveal something of the unconscious desire.
  • Examination of parapraxes A parapraxis is a slip of the tongue, commonly now known as a ‘Freudian slip’. Occasionally it reveals unconscious meaning, particularly in affect-laden situations.
  • Examination of the symbolism of neurotic symptoms Individual patient symptoms may have symbolic meaning in the context of the patient’s history, which can be usefully explored.
  • Exploration of transference/counter-transference The most important areas of repression find expression in the transference relationship.
  • Interpretation Expression of the therapist’s understanding of the meaning of what is currently happening in therapy. May be about the P.777
    current defence mechanisms, explanation for current anxiety, or the presumed underlying desire.
  • Neutrality The withholding of emotional support and directive advice.

Phases of treatment 1–5, 1-hour sessions per week. Therapy may last years rather than months.

  • Diagnostic and assessment sessions Psychodynamic formulation of case. Assess patient suitability and motivation. Explore potential risk factors and formulate plan for dealing with these (e.g. potential development of suicidal behaviour in a socially unsupported patient). Explain methods of therapy. Establish ground rules
  • Early sessions Formulation of problems. Identify unconscious defence mechanisms, key conflicts, style, and defects in personal development.
  • Later sessions Balance between supportive techniques and interpretive techniques (which may increase anxiety). Clarification and guided exploration. Exploration of regression and resistance. Examination of counter-transference and review with supervisor. Interpretation.

Indications and contraindications See general indication for psychotherapy (p. 766). Used in patients where there are severe emotional symptoms which can be understood in psychological terms (e.g. personality disorder, mild to moderate depressive illness, significant impairment in social or interpersonal function). Relatively contraindicated for drug or alcohol dependency, harmful or suicidal ‘acting out’ behaviours, psychotic illness, or in those with severe depressive features. Efficacy There is a lack of standardisation in diagnosis, method, control groups, and improvement measures in psychotherapeutic trials. Suggestive of enduring benefits in expressed symptoms, treatment-seeking, and need for medication. Long-term and enduring improvements noted, associated with length and completeness of treatment. Training Involves education in psychoanalytic history, theory and practice; supervised case work; and personal psychoanalysis. In the UK practitioners are accredited with either the United Kingdom Council for Psychotherapy (UKCP) or the British Confederation of Psychotherapists (BCP). P.778
Brief psychodynamic psychotherapy Freud regarded the open-ended, non-time-limited method of therapy relying on non-guided free association as ‘pure gold’. Nonetheless he recognised that practical considerations would see this alloyed with the ‘bronze’ of a briefer method where interpretation and guidance played a role. Brief psychodynamic therapy is an intervention where the concepts of symptom development and methods of therapy are based on those of psychoanalysis, but where the timescale and number of sessions are reduced. Although driven by economic factors, this is more similar to Freud’s initial practice, where intervention was generally for less than one year. It involves ‘active therapy’, where the therapist attempts to guide free association on more focused topics. Rationale Essentially that the benefits to the patient of the insights and opportunity for change and growth available from long-term psychoanalysis can be achieved in a shorter time scale and that introducing directive elements and focus on particular topics does not necessarily reduce overall treatment effectiveness. How illness is viewed According to psychoanalytic theory. Techniques The methods employed are those of dynamic psychotherapy but are more focused on the ‘here and now’—the patient’s current experience of the world, and techniques are employed to accelerate the process of therapy. These include:

  • Goal setting Explicit identification of the anxiety and defences which are to be tackled.
  • Focus choosing Identification of currently active problem. Repetitive behaviour or emotional response usually related to single transference figure. Explore symptom precipitants and associated early trauma and avoidance.
  • Active interpretation Therapist may guide therapy by use of interpretation at an earlier point than in more prolonged methods.

Phases of treatment Lasts up to one year, usually 20–25 sessions with the termination date decided at outset.

  • Initial assessment Diagnosis, consideration of appropriateness of this method of therapy in this patient (psychologically minded, ability to introspect and contemplate change, availability of external support, absence of psychotic or suicidal features). Consideration of appropriate use of medication.
  • Early sessions Identification of ‘central issue’: an enduring and developmentally relevant anxiety which is stable over time and occurs in different situations. Limited comments from therapist. Usually there is positive transference due to expectation of ‘magical’ change. Identification of main defences, coping styles, and ability to accept and work with interpretations.
  • Middle sessions Exploration of transference. Usual development of resistance.
  • Closing sessions Anticipation of termination. Arrangements for aftercare. Management of the patient who ‘reveals’ new information near the end of therapy.

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Indications and contraindications As for dynamic psychotherapy, appropriate in those individuals with emotional problems which can be understood in psychological terms. This briefer therapy may be more appropriate in those with clear and easily identifiable goals, problems which can be understood as a focal conflict, and where there are recent rather than chronic or life-long problems. Efficacy Evidence for treatment effectiveness as measured in length of illness and global functional measures. Trials comparing effectiveness with other brief therapies (e.g. CBT and IPT) are required. P.780
Group therapy Psychotherapy can be defined as treatment based on a dialogue within a relationship. Group therapy methods involve a relationship with a specially created community, with the dialogue occurring between group members as well as with a therapist. Group methods were developed in the early 20th Century following observations of beneficial group effects in TB patients. Groups vary as to whether their patient population has single or multiple diagnoses; whether the therapist is actively involved or supervisory; whether the membership is closed or open after the group starts; and whether they exist for a fixed term or are ongoing. Types of group

  • Activity groups Used for patients unsuitable for other group activities. Focuses may be art, gardening, computing, etc. Used in LD, chronic psychosis, and other disorders with chronic functional impairment. Fosters social skills, adaptive behaviours, and allows confrontation of anxiety and phobias.
  • Support groups Peer support in LD, chronic illness, and also for those caring for others. Therapist may have a psychoeducational role.
  • Problem-focused groups E.g. alcohol or drug dependence, ‘Hearing voices’, sexual deviancy. No analytic work. Focus on mutual support with addition of group examination of strategies for change. Peers may be experts at identifying resistance and rationalisation for avoiding change in other group members. Where the problem is a chronic illness the therapist may again take on a psychoeducational role.
  • Psychodynamic groups All of the above elements plus aim of lasting change through exploratory therapy. (Therapy may be viewed as individual therapy which takes place in the group setting, or as psychotherapy of the group as a whole.)

Techniques

  • Free-ranging discussion—the group form of free association.
  • Psychoeducation.
  • Allowing the opportunity for individual members to confront the effects of their behaviour on others while providing a supportive milieu during change.
  • Encouraging group specific process: mirroring (duplication of experience), amplification (increase in emotional resonance by sharing), catharsis (supported ventilation of emotion).
  • Analysis of group dynamics (e.g. leadership, group structure, individual roles) to understand reasons for progress (or the lack of it).
  • Clarification/interpretation/confrontation with individuals.
  • Group curative factors described by Yalom1 are: installation of hope, universality, imparting information, altruism, corrective of early family group, development of socialisation, imitation of adaptive behaviour, interpersonal learning, group cohesion, catharsis, existential factors.

Phases of therapy

  • Early sessions Set-up and engagement, formulation of rules and establishment of goals, focus on leader.
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  • Middle sessions Adaptation, potential for conflict, discussion of authority, establishment, intimacy, and group coherence
  • Closing sessions Negotiation of termination, agreement that goals have been achieved, reflection on experience of group.

References 1 Yalom I (1975) The theory and practice of group psychotherapy. Basic Books. New York. P.782
Basic learning theory Behavioural psychology is a method for understanding the development of knowledge and behaviours in organisms. In an individual organism these are shaped by environmental influences and can change as a result of experience. Learning theory concerns the testing of methods to produce behavioural change through changing environmental influences. The two basic learning processes are classical (Pavlovian) conditioning—learning what goes with what, and operant (Skinnerian) conditioning—learning to obtain reward and avoid punishment. Although most abnormal mental processes and mental illnesses are not amenable to understanding purely in terms of conditioning, understanding of learning theory is helpful in conceptualising the development and maintenance of abnormal mental processes and provides a rationale for behavioural and cognitive behavioural treatment approaches. Classical conditioning In the initial experiment, Pavlov presented a dog with food which produced the response of salivation. Here the food is the unconditioned stimulus (US) and the salivation is the unconditioned response (UR). A neutral stimulus such as a bell ringing is not associated with any unconditioned response. However if a bell is rung immediately before the food is presented, after a number of repetitions the dog will salivate in response to the bell alone. Now the bell is a conditioned stimulus (CS) producing a conditioned response (CR), the salivation. Acquisition The development of the association between the UR and the US producing a CR. In animal experiments this can take between 3 and 15 pairings. Where there is sufficient emotional involvement acquisition can occur with as few as one pairing. Extinction The loss of the association between the CR and the CS. Occurs when the CS is repeatedly not followed by the US. Generalisation The phenomenon where similar stimuli to the initial CS produce the response. N.B. For emotional disorders the response is usually an emotion rather than a behaviour. For example, an initial encounter with a large, barking dog which bites the individual can produce the CR of fear to the generalised CS of seeing a dog. The affected individual may then avoid all contact with dogs and so avoid the unpleasant CR. However, because there is no occasion when the CS of seeing a dog is not paired with the CR of fear, there is no opportunity for extinction to take place. Techniques based on classical conditioning concepts

  • Systematic desensitisation (p. 784) Presentation of situations more and more similar to the CS are paired with relaxation techniques, in order to eventually break the association between the CS and the CR.
  • Flooding (p. 784) Presentation of the full CS without the possibility of withdrawal from the situation. The initial unpleasant experience of the CR gradually diminishes.

Operant conditioning The experimental techniques and rules of operant conditioning were developed by Thorndike and refined by P.783
Skinner. The basic principles of operant conditioning are that if a response to a stimulus produces positive consequences for the individual it will tend to be repeated, while if it is followed by negative consequences it will tend not to be repeated. In the original experiments rats were placed in a box containing a lever which, when pressed delivered a pellet of food. Eventually the rat would press the lever and be rewarded. The rat would then press the lever with increasing frequency. (Note that operant conditioning doesn’t rely on insight on the part of the rat.) Acquisition The linkage of the response (pressing the lever) with the reinforcer (receiving the food). Reinforcement Can occur after every response (continuous reinforcement) or only after some responses (partial reinforcement). Behaviours conditioned by partial reinforcement extinguish at a much slower rate than those conditioned by continuous reinforcement. Extinction Occurs when the response is no longer followed by the reinforcer. Techniques based on operant conditioning concepts

  • Behaviour modification (p. 784).
  • Aversion therapy (p. 784).

P.784
Behaviour therapy Techniques based on learning theory are utilised in order to extinguish maladaptive behaviours and substitute adaptive ones. Systematic desensitisation Holds as a central tenant the principle of reciprocal inhibition (i.e. anxiety and relaxation cannot coexist). Systematic graded exposure to the source of anxiety is coupled with the use of relaxation techniques (the ‘desensitisation’ component). Effective for simple phobias, but less so for other phobic/anxiety disorders (e.g. agoraphobia). Process in a typical case is as follows:

  • Patient identifies the specific fear (e.g. cats).
  • Patient and therapist develop hierarchy of situations provoking increasing levels of anxiety, (e.g. stroking a cat on one’s knee > touching a cat > having a cat in the room > looking at pictures of cats > thinking about cats).
  • Patient is instructed in relaxation technique.
  • Patient experiences the lowest item on the hierarchy while practising the relaxation technique and remains exposed to the item until the anxiety has diminished.
  • The process is repeated until the item no longer produces anxiety.
  • The next item in the hierarchy is tackled in similar fashion.

Flooding/implosive therapy High levels of anxiety cannot be maintained for long periods, and a process of ‘exhaustion’ occurs. By exposing the patient to the phobic object and preventing the usual escape or avoidance, there is extinction of the usual (maladaptive) anxiety response. This may be done in vivo (flooding) or in imagination (implosion). Behaviour modification Based on operant conditioning. Behaviour may be shaped towards the desired final modification through the rewarding of small, achievable intermediate steps. This can be utilised in behavioural disturbance in children and patients with learning disability. Other forms of behavioural modification include the more explicit use of secondary reinforcement, such as ‘token economy’, in which socially desirable/acceptable behaviours are rewarded with tokens that can be exchanged for other material items or privileges, or ‘star charts’ where children’s good behaviour is rewarded when a certain level is achieved. Aversion therapy and covert sensitisation The use of negative reinforcement (the unpleasant consequence of a particular behaviour) to inhibit the usual maladaptive behavioural response (extinction). True ‘aversion’ therapy (e.g. previously used to treat sexual deviancy) is not used today, however, covert techniques (e.g. the use of Antabuse in alcohol dependency) can be (at least partially) effective. P.785
P.786
Cognitive behaviour therapy Cognitive behaviour therapy (CBT) was developed by Beck in the 1960s and described in Cognitive Therapy of Depression1. Its development was prompted by the observation that patients referred for psychotherapy often held ingrained, negatively skewed views of themselves, their future, and their environment. Treatment is based on the idea that disorder is caused not by events, but by the view the patient takes of events. It is a short-term, collaborative therapy, focused on current problems, whose goals are symptom relief and development of new skills. Rationale Behaviours and emotions are determined by the person’s cognitions. Some pathological emotions are as a result of ‘cognitive errors’. While underlying emotions are not amenable to examination and behavioural change, the cognitions are. If the person can be helped to understand the connection between cognitive errors and distressing emotion, they can try methods of change. CBT aims to ‘change the way you feel by changing the way you think’. How illness is viewed In some personality types and in mental illness there are errors in the perception of risk, logical errors, and errors in the processing of information (i.e. cognitive distortions). These distortions relate to self, world, and future (Beck’s cognitive triad). The model is: events → faulty cognitive appraisal → emotional response → maladaptive behaviour → (behaviours/emotions) = pathology. Cognitive errors thus lead to dysphoria and maladaptive behaviour. These errors originate in childhood learning, internalised family/cultural attitude, and early traumatic experiences. The cognitive model is a guide for therapy, not a comprehensive model of illness causation, and does not preclude neurochemical or other factors as important in symptom development nor preclude the use of pharmacological treatments. Techniques The therapist is very active in CBT. The patient and the therapist are viewed as working together in spirit of scientific enquiry to explore the problem and solutions—‘collaborative empiricism’. The therapist aims to assist the patient to: monitor cognitions; identify cognitive errors; understand maladaptive schema; and explore with them strategies to challenge and change these and examine the resultant symptomatic effects. CBT makes use of behavioural, cognitive, and experimental techniques to treat patients.

  • Behavioural techniques Activity scheduling; graded assignments; exposure; response prevention; distraction; relaxation training; assertiveness/social skills training.
  • Cognitive techniques Psychoeducation, including reading assignments (e.g. ‘Coping with depression’); identifying automatic thoughts; Socratic questioning (‘If that were true, what would it mean… and what would that mean… etc.?’); role play; thoughts diary; examining the evidence (e.g. ‘let’s suppose that’s true—what happens then?’); ‘working through the options’; thought rehearsal.

Phases of treatment A short-term treatment, with the initial assessment being followed by 6–20, hour-long sessions. Clinical attention is P.787
primarily focused on events in the ‘here and now’. Each session generally proceeds as follows: deal with emergencies; jointly set agenda; review homework task; feedback; focus on specific items guided by current problems; suggestion of cognitive or behavioural techniques to challenge automatic thoughts/core schema; give homework. Indications and contraindications CBT is considered as an active treatment requiring patient understanding and collaboration. Patients should therefore be motivated and be able to link thought and emotions. In addition to the general contraindications to psychotherapy (p. 766), CBT is contraindicated in LD and dementia. Indicated in:

  • Mild to moderate depressive illness.
  • Eating disorders (anorexia nervosa and bulimia nervosa).
  • Anxiety disorders.
  • In selected patients, may have a role in personality disorder, substance abuse, and in the management of chronic psychotic symptoms.

Efficacy There is good evidence for effectiveness in depressive illness, eating disorders and anxiety disorders. CBT is at least as effective as pharmacotherapy2 in mild to moderate depression and may be more effective in long-term follow-up (e.g. at preventing relapse). Cognitive errors CBT identifies two levels of cognitive errors: automatic thoughts and core schemas. Automatic thoughts can be perpetuated by never being challenged consciously or by novel experience. Schemas are a person’s ‘rules’ for behaving, based on fundamental beliefs and shaped by previous (and current) experiences. Automatic thoughts

  • Selective abstraction
  • Arbitrary inference
  • All or nothing thinking
  • Magnification/minimisation
  • Personalisation
  • Catastrophic thinking
  • Overgeneralisation

Fundamental beliefs (in schema)

  • Basic rules for making sense of environmental information, (e.g. ‘a person must do every thing right to be successful’, ‘a good person always retains emotional control’).

References 1 Beck AT, Rush AJ, Shaw BF, et al. (1979) Cognitive therapy of depression. New York, Guilford. 2 Dobson KS (1989) A meta-analysis of the efficacy of cognitive therapy for depression. J Consult Clin Psychol 57, 414–19. P.788
Rational emotive therapy Developed by Albert Ellis in 1955. A ‘reality-based’, short-term therapy aimed at ‘cognitive re-structuring’, with many similarities to the later developed CBT. Rationale Harmful emotions and personally dysfunctional behaviours can arise as a result of irrational thinking (see opposite). Individuals retain responsibility for their own emotions and actions and can effect change to their patterns of irrational thinking. As well as reducing harmful emotions and behaviours, this change in thinking can produce greater personal satisfaction, potential for growth, and ability to resolve future negative events successfully. How illness is viewed Emotional suffering is a secondary problem to the primary practical problems which are inevitable and part of life. It is the person’s emotional reaction to an event, rather than the event itself, which determines the degree of distress. Irrational ideas can cause emotional suffering in the absence of external trauma. Techniques Therapy proceeds by guiding the patient to identify, challenge, and change their irrational thoughts. These can be viewed as a series of ‘musts’ relating to oneself, others, and the environment. So, for example:

  • ‘I must always be on top of things or else I’m no good at what I do’
  • ‘Others must be there for me, otherwise they don’t care at all’
  • ‘Life must be free of worry otherwise I won’t be able to cope’

The therapist aims to encourage the patient to examine their basic beliefs; to encourage the replacement of irrational with rational thinking; and to examine the resultant change in their emotional response. Therapy is active, focused on the ‘here and now’, and is largely a teaching and learning process. The therapist uses guided discussion, logic, real-life challenges, and appropriate humour to challenge irrational thinking. Phases of treatment

  • Early sessions Explain rationale for therapy and explore current stresses and negative events. Explore ‘musts’ and question their basis. Direct patient towards activities which question irrational beliefs.
  • Middle sessions Go beyond awareness of irrational thinking and explore the maintenance of emotional disturbance and self-defeating patterns of thinking.
  • Later sessions Guide the development of new patterns of thinking and enable the patient to observe and minimise the development of future maladaptive thinking patterns.

Indications and contraindications Useful in mild to moderate depression, anxiety disorders, eating disorders. Contraindications are those to any psychotherapy (p. 766). Efficacy There is evidence that RET is better than placebo or ‘treatment as usual’ for mild to moderate depression and anxiety disorders1. P.789
However, its similarity to CBT means that most recent meta-analyses include RET with CBT when looking at outcomes, making comparisons with other cognitive/behavioural or pharmacological therapies difficult. Ellis identified 12 basic irrational beliefs

  • Everyone should love and approve of me for me to be lovable at all.
  • I should always be successful and ‘on top of things’; if I’m not, I’m a failure.
  • People who are bad should be made to ‘pay the price’.
  • I can’t stand it when things do not go the way planned.
  • External events cause most of my unhappiness and as I don’t have any control over these things I can’t do anything about my problems.
  • When the situation is going badly I can’t help worrying all the time.
  • It is easier for me to avoid thinking about tense situations.
  • I need someone to be with and lean on.
  • Things have been this way so long, I can’t do anything about these problems now.
  • When my close friends and relatives have serious problems it is only natural that I get very upset too.
  • I don’t like the way I’m feeling but I can’t help it. I just have to accept it.
  • I know there is an answer to every problem and I should be able to find it.

Most of these fall into 4 basic categories: unwarranted conclusions, misattribution of cause, catastrophising, and overgeneralising. References 1 Engels GI, Garnefski N, Diekstra RF (1993) Efficacy of rational-emotive therapy: a quantitative analysis. J Consult Clin Psychol. 61, 1083–90. P.790
Interpersonal therapy Interpersonal therapy (IPT) was developed in the 1970s by Klerman and Weissman as a treatment for depressive illness and later developed for use in other disorders. It is a time-limited and disorder-focused therapy which deals with symptoms in the ‘here and now’. It is described in a manual for practitioners1 and a guide for patients2. Rationale The development of psychopathology can be understood as a result of life events occurring at any time in life. Emotional problems are best understood by studying the interpersonal context in which they arise. Life events related to illness development include: grief, interpersonal disputes, change of role, and interpersonal deficits. These events are not viewed as directly causing the episode of illness, but helping the patient to understand their role in the evolution of illness and resolving the interpersonal problem is seen as a route to recovery. The therapy’s role in various disorders is rooted in RCT evidence for efficacy. How illness is viewed Illnesses are viewed as medical disorders and are diagnosed according to standard criteria (e.g. DSM-IV) and rated in severity by rating scales (e.g. BDI). The patient is diagnosed as ill and explicitly given the ‘sick role’ with its benefits (freedom from guilt at condition, time-out from normal social role) and responsibilities (to seek treatment and get better). Techniques The focuses of treatment are the current interpersonal relationships and their relationship to the development of illness. Interventions are directed at dysfunctions in social relationships rather than underlying beliefs (cf. CBT). Basis for planning treatment is inventory of all close relationships. Focus is on role transitions (e.g. new mother, job loss) or role dispute (e.g. work difficulties, relationship problems). Phases of treatment Treatment lasts for 12–16, hour-long weekly sessions, roughly divided into three phases:

  • Phase one (sessions 1–2) Standard psychiatric history; risk assessment; diagnosis and communication of diagnosis to patient; establishment of the ‘sick role’; explanation of rationale for treatment and its aims and processes; assessment of need for psychotropic medication and prescription if indicated; completion of interpersonal inventory (description of current relationships); and psychotherapeutic formulation based on identifying the extent of problems in any of four areas mentioned above.
  • Phase two (sessions 3–11) Each session begins with enquiry as to events since the last session. The therapist is directive and hopeful about the possibility of change which may be minimised by a depressed patient. The patient is encouraged to identify and carry through change in interpersonal relationships and to test the possibility of consequent improvement in their symptoms. Therapeutic techniques are specific to the problem under review; they include role-play, catharsis, facilitation of grief, and relationship problem-solving. ‘Role disputes’ can be resolved by renegotiation, acceptance of impasse, or dissolution.
  • Phase three (sessions 12-end) Assessment of improvement; plan for termination of therapy or exploration of other form of treatment; identification and planning for the possibility of re-emerging symptoms.

P.791
Indications

  • Mild to moderate depressive illness
  • Bulimia nervosa
  • Dysthymic disorder

Patients without significant social dysfunction do best. Possibly indicated especially in atypical depression. It is not indicated in the treatment of substance abuse or as monotherapy in patients with severe depression or psychotic features. Efficacy The efficacy of IPT is currently being assessed in panic disorder, bipolar disorder, borderline PD, and somatisation disorder, and indications may broaden in the future. RCT evidence of similar outcome to imipramine treatment in major depression with improved psychosocial functioning at 1-year follow-up. References 1 Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES. (1984) Interpersonal therapy of depression. Basic books, New York. 2 Weissman MM. (1995) Mastering depression: a patient guide to interpersonal psychotherapy. Graywind Publications, Albany, New York. P.792
Cognitive analytic therapy Cognitive analytic therapy (CAT) is a relatively new therapy method introduced by Anthony Ryle in 1990. It aims to bring together ideas from both dynamic and behavioural therapies by attempting to explain psychoanalytic ideas in cognitive terms. Rationale Problems such as depression, anxiety disorders, and interpersonal difficulties cause emotional suffering and also hinder the ability of the individual to make positive change. These problems can often be understood in the context of an individual’s history and early experiences and can be prolonged by habitual coping mechanisms. Through collaborative therapy these mechanisms can be identified, understood, and changed. How illness is viewed Traumatic childhood and adolescent experiences can give rise to coping mechanisms to protect the individual from conscious distress. These maladaptive mechanisms can be inappropriately maintained into adult life when they give rise to emotional symptoms such as anxiety and depression and destructive behaviours such as self-harm. Although harmful these behaviours are maintained by ‘neurotic repetition’. Neurotic repetition has 3 essential patterns:

  • ‘Traps’—negative assumptions generate acts that produce consequences, which in turn reinforce assumptions.
  • ‘Dilemmas’—a person acts as if available actions or possible roles are limited and polarised (called ‘false dichotomy’) and so resists change.
  • ‘Snags’—appropriate goals or roles are abandoned either because others would oppose them or they are thought to be ‘forbidden’ or ‘dangerous’ in light of personal beliefs.

Techniques The ‘three Rs’ of CAT are recognition of maladaptive behaviour and beliefs, reformulation of these (the main ‘work’ of therapy), and revision. The reformulation is agreed between therapist and patient and documented in a ‘psychotherapy file’. This reformulation is expressed in narrative and diagrammatic form and considers both past history and current problems. It is used throughout therapy to guide the active focus, to set homework, and to enable recognition of transference/counter-transference. Phases of treatment Therapy involves active participation from both parties.

  • Assessment Explanation of rationale of method of therapy. Planning of number and timing of sessions (8–24 sessions, normally 12).
  • Early sessions (1–3) Patient asked to begin ‘psychotherapy file’ exploring common traps, dilemmas, and snags. Diary keeping to monitor moods and behaviours. Recapitulation of early experiences and narrative of current relationships.
  • Middle sessions (4–8) Agreement on reformulation of problems with written and diagrammatic description of ‘target problem procedures’. Exploration of methods of change, (called ‘exits’) via work in sessions and in homework.
  • Ending sessions (9–12) Identification and recapitulation of key themes which emerged during therapy. Both therapist and patient P.793
    write ‘goodbye’ letters summarising progress and formally closing the relationship. There may be a planned 3-month review appointment.

Indications and contraindications As for other cognitive therapies. Efficacy Ongoing RCTs examining effectiveness in personality disorders and comparing CAT with other methods. P.794
Dialectical1 behavioural therapy Dialectical behaviour therapy (DBT) is an integrative therapy drawing on ideas from behavioural, cognitive and psychodynamic therapies, as well as from Eastern philosophy and meditation techniques. It was introduced in 1991 by Marsha Linehan2,3 and colleagues as a treatment for borderline personality disorder. Rationale Patients with borderline personality disorder suffer from significant psychiatric morbidity and a mortality related to completed suicide. They are a difficult group of patients to treat as their characteristic patterns of behaviour tend to challenge therapeutic progress and exhaust therapist resources (‘burnout’). Such individuals can however learn more adaptive responses later in life, with subsequent improvement in functioning and quality of life and reduction in morbidity and mortality. How illness is viewed A combination of abnormal early experiences (‘invalidating environment’) and currently poorly understood biological factors leaves some individuals with abnormal emotional reactions to life events and interpersonal crises. They also have less well-developed methods of coping with their own emotional responses (less ‘emotional modulation’) and a habitual pattern of maladaptive behaviours, (e.g. self-harm). Lack of emotional modulation means that the person will look to others to assist with emotional stress but will also have a limited ability to maintain relationships. Techniques Hierarchical view of treatment aspirations

  • Reduction in behaviours which cause harm (DSH and suicidal).
  • Reduction in behaviours which interfere with therapy.
  • Reduction in behaviours which diminish quality of life and personal relationships.

Cognitive and behavioural methods

  • Person of, and relationship with, the therapist seen as the main ‘reinforcer’ of adaptive behaviour and in-therapy analysis of maladaptive behaviour seen as aversive.
  • DBT involves a variety of approaches: individual therapy group skills training (emotional understanding, tolerance of distress, Eastern meditation techniques), availability of the therapist for telephone contact between appointments.
  • Key techniques include: validation (recognising distress and behaviours as legitimate and understandable but ultimately harmful) and problem solving (agreeing with patient a more appropriate approach given all the evidence).

Preserving therapist morale Therapist supported by group of other DBT therapists. P.795
Phases of treatment

  • Assessment Orientation and commitment to therapy. Commitment to therapy for specific period. Aim at reduction of DSH and suicidal behaviours. Specific attention to those behaviours which inhibit successful therapy. Attendance at other therapies as directed.
  • Stage 1 Focuses on suicide and DSH prevention with recording of episodes, exploration of internal and external antecedents. Weekly DBT skills group introduces basic skills (e.g. ‘mindfulness training’, focusing on the ‘here and now’, and learning to tolerate aversive states). DSH may be viewed as understandable in the context of the patient’s current situation but the therapist always argues on the side of life and ways of making it more tolerable.
  • Stage 2 Focuses on emotional processing of previous traumatic experiences. Underlying historical causes of dysfunction. Memories of abuse. Flashbacks. Exposure and distress tolerance techniques.
  • Stage 3 Aims to develop self-esteem and establish future goals. Self-esteem and adaptive behaviours are individual agreed goals.

Indications and contraindications DBT methods are described specifically for patients with borderline personality disorder. Efficacy The original DBT group produced RCT evidence of reduced DSH, reduced admission, and improved retention in therapy compared with ‘treatment as usual’. References 1 ‘Dialectic’ refers to a means of arriving at the truth by examination of the argument (the ‘thesis’ the contradictory argument—the ‘antithesis’) and resolving them into a coherent ‘synthesis’; 2 Linehan MM (1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press. 3 Linehan MM (1993) Skills Training Manual for Treating Borderline Personality Disorder. New York: The Guilford Press.

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