week 5 notes.docx

Contents Week 1: Clinical Assessment and Interview 2 Week 2 8 Week 3 14 Week 4: Evidence based practice 20 Week 4: Person-Centred Counselling 21 Week 4: EBPP and Carl Rogers 25 Week 5: CBT 25 REBT Rational Emotive Behaviour Therapy 25 Cognitive therapy & CBT 31 Week 6 41 ACT 41 6 Core Therapeuti...

Contents Week 1: Clinical Assessment and Interview 2 Week 2 8 Week 3 14 Week 4: Evidence based practice 20 Week 4: Person-Centred Counselling 21 Week 4: EBPP and Carl Rogers 25 Week 5: CBT 25 REBT Rational Emotive Behaviour Therapy 25 Cognitive therapy & CBT 31 Week 6 41 ACT 41 6 Core Therapeutic Processes = Psychological Flexibility 44 Week 7 Compassion Therapy 52 Week 8 61 Emotion-focused therapy 61 Week 9 Solutions focused therapy 67 Week 10 - Family & Couples therapy 73 Couples Therapy: The Gottman Method 77 Week 11 81 Cultural competence 81 Week 1: Clinical Assessment and Interview What does a psychologist do? Treatment of mental health problems – clinical range Psychological intervention/psychotherapies Evidence based Assumptions Goal of tx not to end of with absence of symptoms – dial down intensity & frequency Work on individual – but context, history, relationships etc mtter 3rd wave psych – not a deficit model but a strengths – more holistic Psych assessment Gather info about people Research and for individuals Assessment in clinical settings Information about one person (or a few) Information usually used to answer a particular question What is the nature of this person’s problem? – why they have engaged – dev shared understanding Major elements of a psychological assessment: Interview Structured assessment (i.e. testing) In-situ (behavioural) observation Other sources of information (referral, other informants) The interview The objective of an interview is to gather information Like structured tests, the information (data) obtained through an interview can vary Must be valid & reliable Unconditional positive regard Interview skills In all cases mutual interaction Interviewer’s actions affect interviewee’s action … and vice versa Affects completeness, reliability, and validity of data obtained Self-awareness - monitor your own responses If they ask personal questions “I’m interested in why you want to know, how you think that might help you..” Features of a good interview: Safe Relaxed Warmth Openness Concern and interest Some things not to do: Convey negative judgements (verbally or non-verbally) Probe using too many ‘why’s Rely on closed questions Speak more than necessary – reduce our influence Active listing skills (aka micro-counselling skills) Core technique for interviewing Let the interviewee know that They are being heard (being taken seriously) It is OK to continue talking about the current topic Initially very difficult to implement but become automatic with practice Questions asked to help client not satisfy your curiosity Self-disclosure to build rapport but fine line around boundaries Interview in clinical setting First build rapport Collect information on: The person The presenting problem 5P (presentation, predispose, precipitating, perpetuating, protective) Description; onset and progression; intensity and duration; changes in frequency Attempts to solve Antecedents/consequences – what happened recently, consequences – how does this impact you – can you tell me about that? Formal treatment Don’t accept “I am depressed” – what does that mean for them – symptoms, impacts, length, intensity, how currently solve, what they do, don’t do History of presenting problem Medical and psychiatric history Personal and family history MSE Threats to interview validity Bias (loss of objectivity) – get curious Primacy effect – first impressions Halo effect – initial positive impression General standoutishness – prominent characteristic Cultural misunderstanding – e.g. eye contact, emotional reservedness Labelling and confirmation biases If handover notes consider not reading Structured interview tools Increase reliability Decrease the influence of bias E.g. Structured Clinical Interview for the DSM-5 (SCID-5) Most widely used of these tools Long admin time but ‘skip’ format and stand-alone modules. Background info should be used in formulation and before making final decisions about diagnosis Wording very useful on where to start – symptoms etc Behavioural observations An interview and/or structured psychological test only gives you part of the information you need, esp when Client has limited insight Client is young and/or can’t express internal states Presenting problem is complex Regardless, observed behaviours are needed to confirm/disprove hypotheses based on interview or test data Non-verbal data Dress Tone of voice Eye contact Emotional content of speech Posture, psychomotor activity Telehealth may need to ask how self-care is going Mental status exam A way of systematically attending to, recording, and reporting behavioural observations Based on physical medical exam format Reviews the major systems of psychiatric functioning Information is used to form clinical judgements and assist with diagnosis Clinicians vary widely in how they conduct the MSE Can be structured and/or unstructured Instruments are available, both commercially and free, which provide standardised questions Not used in a formal way by all psychologists Specific assessment tools usually more reliable and valid for some sections Good practice - think about MSE components during every interview Increases the reliability of the data used for diagnoses and case formulation Draws attention to the key features that describe the client Allows another clinician to determine if the client’s status has changed without having previously seen them MSE components Appearance Clothing Neat/dishevelled, clean Casual/formal - appropriate to setting? Physical handicaps Presence / Absence Personal hygiene Clean/dirty; body odour Grooming Build/posture Slumped Rigid or tense Unusual features Behaviour Cooperation and attitude Rapport, friendly Suspicious, hostile, evasive Appropriate, excessive Nonverbal behaviour Motor activity (fidgety, restless/agitated, slow, lethargic) Tics, mannerisms Facial expression(s) Eye contact Mood and affect Affect: Predominant emotion observed in facial expression or voice tone and content, how mood is observed Type - Euthymic (normal mood), dysphoric (depressed, irritable, angry), euphoric (elevated, elated, anxious) Range - Full (normal)/restricted/blunted or flat Congruency with stated mood - consistent/incongruent Appropriateness (to setting; context) Stability – Stable, labile Mood: How the client tells you they feel Angry, irritable, happy, anxious, afraid, depressed, sad, apathetic Speech Speech pattern Fluency, rhythm, paraphasias, articulation, slurred Voice tone Pitch, volume General flow and rate Rapid/slow Pressured/controlled Poly-/monosyllabic Hesitant/latency Impediments or accents Thought processes Organisation Organised and goal-directed Logical and sensible progression or flight of ideas Flow Fluid Stopping or blocking Loss of train of thought Loosening of associations - Illogical shifting between unrelated topics Circumstantial - Provides unnecessary detail but eventually get to the point Tangential - Moves from thought to thought that relate in some way but never get to the point Flight of ideas - Quickly moving from one idea to another (mania) Perseveration - Repetition of words, phrases or ideas “Word salad” - Randomly spoken words Thought content Obsessive thoughts or ideas Report of compulsive actions Fears or phobias Delusions Thought insertion – belief that thoughts can be put into the patient’s mind Thought withdrawal – belief that thoughts can be removed from patient’s mind Thought broadcasting – belief that others can hear the patient’s thoughts Perceptions Cognition Orientation Person Awareness of who they are and what the examiner’s role is Place Awareness of present physical location and location of their home Time Awareness of year, month, date, day, time of day Situation Awareness of what is transpiring (the evaluation) and why they are being evaluated Attention and concentration Distracted Focussed/selective attention Ability to sort and discriminate important elements Sustained attention Maintain attention without external prompts Divided attention Ability to sustain attention on multiple demanding tasks Attentional control/switching Ability to switch the focus of attention smoothly between tasks/objects/etc. Memory Immediate Within interview Recent Recent life events Long-term Intellectual functioning Estimate of level of functioning based on: Behaviour Vocabulary usage Historical information Organisation of thought processes Insight Recognition of present status and problems “Psychological-mindedness” Awareness of effect of own behaviour on others Judgement Level of decision-making abilities Current Historical Nature of problem-solving approach Rational Impulsive Methodical Irresponsible Week 2 Psychotherapy v Counselling Psychotherapy/CBT Clinical population Psychiatric conditions Specific interventions for specific problems A focus on the therapeutic relationship and process Person-centred approach Psychodynamic approach A focus on the therapeutic content Cognitive-behavioural approach Counselling Everyday, “normal” challenges and problems E.g. Relationship counselling Grief counselling Drug and alcohol Making difficult decisions – abortion, relocation, genetic counselling Differences between Commonalities Importance of the therapeutic relationship Congruence, unconditional positive regard, empathy (necessary and sufficient conditions for therapeutic change?) Importance of microskills Active listening Reflecting feeling and meaning Asking questions Confrontation Helping clients help themselves Micro counselling skills Skills for active listening, communicating empathy, helping clients challenge themselves Attending Reflecting Questioning Challenging/confronting Focusing Listening and Attending Non-verbal listening The use of nonverbal skills to communicate to the speaker that you are listening and understanding Reflective listening The key element of reflective listening is hypothesis testing. It asks, in a way, “Is this what you mean?” Thomas Gordon’s Model of Listening There are at least 3 places where communication can go wrong: the speaker does not say exactly what is meant the listener does not hear the words correctly the listener gives a different interpretation to what the words mean The process of reflective listening is meant to connect the two bottom boxes (4) to check whether “what the listener thinks the speaker means” is the same as “what the speaker means.” Listening Reflective listening is… Statements rather than questions Guessing what comes next Giving voice to what the client is not saying “You” statements So you feel… It sounds like you… You’re wondering if… Attending behaviour Pay attention to client in overt ways that communicate respect and interest. What impact would poor attending have on the client? Eye contact Cultural considerations Vocal qualities Loudness, pitch, rate, inflection Verbal tracking Maintain focus, self reflect on what you are tracking and why? Body Language How might you display attention through body language Mirroring Always stay aware of how you are attending. Your goal in interviewing is to be a good listener through the use of specific, observable behaviour which are culturally appropriate: Using varied eye contact to communicate with the client Using a natural relaxed posture and gestures. No need to sit rigid and “professional.” Use your body to communicate your involvement Use a natural vocal style If you get lost and can’t think of anything to say, simply hesitate a moment and think of something said earlier that interested you. Go back and make a comment, or ask a question about that topic. Remember to use your posture, gesture and facial expressions and voice to send messages you want clients to hear such as “I am listening to you very carefully” or “I know what you’re saying is difficult for you”. Secondly, become aware of the messages your clients are sending to you through their non-verbal behaviours. SOLER Egan (2007) used acronym SOLER to encapsulate the non-verbal skills required S – sitting at a comfortable angle and distance O – open posture; arms and legs uncrossed L – leaning forward from time to time; looking genuinely interested, listening attentively E – effective eye contact without staring R – remaining relatively relaxed What to say If you don’t know what to say, just listen. Listen more, listening with openness, and it will come to you. Experience reduces the panic of not knowing what to say. Which you don’t have yet Develop the ability to sit in the emotion and wait. Silence is key Most of this course will be about teaching you to become comfortable with uncertainty and leaning into vulnerability and humility. Non-directive listening behaviours As a therapist we must selectively attend to certain material. Must reflect on what we are attending to, how we are expressing that and why we are choosing that during the session. Silence Can frighten both therapists and clients. Most feel awkward in silence What does silence do for a client? Encourages talk Allow space to reflect and recover But also may scare clients away as puts on pressure to speak. “Why should I pay for a therapist that just sits there and doesn’t say anything?” Important to explain and reflect on silence in session Force yourself to wait before speaking Keep in mind that sessions are time for clients self-expression, not time for you to prove you are useful. Don’t overuse silence, sometimes you breaking the silence is OK. Just experiment with waiting sometimes also. Be aware that silence can exacerbate emotional crisis and psychosis. Use attending skills during silence. Monitor what you body is doing. Invite client to speak though empathetic statements and invite to free associate Experiment with silence in your everyday life. Talk to friends about it. Reflection of content – paraphrasing Encourages client to continue exploring own thoughts and ideas. Clearly and briefly reflect the most important thing the client has just said. Try for one sentence, use own words. Allow time for both to think. Avoid interpretation yet do not parrot. Aim for genuine, own words The Simple Paraphrase Doesn’t add meaning or direction Simply rephrase, reward and reflect The Sensory-Based Paraphrase Neurolinguistic Programming, reflection using the same representational system as the client uses Check for visual (‘I see’), auditory (‘sounds like’) or kinesthetic (‘I feel.’) focus in cleints word choice. Metaphorical Paraphrase Using metaphor to capture clients central message May also involve reflecting using same metaphor as client ‘Speak their language.’ Intentionally Directive Paraphrases Solution focused. Show empathy while at the same time helping clients to move beyond the negative or traumatic feelings ‘Just as one cannot not communicate, one cannot not influence.’ Useful formats to state these reflections are: You’re saying........ In other words....... It sounds as if......... What I seem to be hearing is....... So what you’re saying is....... So it’s as though....... From listening to you, would it be correct to say that...... Reflection of feelings Reflecting back the feelings within a statement/what the client says Good way to help the client connect with their feelings as we often live in our heads (thoughts) Also lets clients know, through and emotionally oriented paraphrase, that you’re tuned in to their emotional state. Catharsis involves releasing troubling emotional feelings Nondirective feeling reflection Restate and reflect only the emotional content that you clearly hear the clients say Note that feelings will move toward intimacy, must think about how ready your client is for this intimacy. What might a client be less ready for emotional content? You can minimise potential negative reactions by using tentative language, especially when ‘guessing’ emotion or purposefully overstating emotion. “seems like…” Some examples of how to structure a reflection are: You’re...... You feel......because...... I sense that you feel..... So you feel as though..... The situation has left you feeling..... I seem to be picking up you are feeling..... Could it be that you are feeling....... It seems as if you are feeling....... Aim of paraphrasing To check to see if you understand what is being said (not parroting) To communicate empathy I am listening I understand To encourage client to elaborate To highlight and focus To extend Summarising “Let’s see if I can pull together what you’ve been saying…” “Let me summarize and you tell me if I’m on the right track…” Helps to focus the session Helps you keep track of what is said Encourages elaboration Enables new perspective/big picture view Helps close a theme Getting your client to summarize Week 3 The Therapeutic Alliance Therapy process research Model – technique factors 15% Factors unique to specific theories or therapy Refers to theory-specific methods and processes that therapists use to intervene in the lives of their clients Models and techniques in and of themselves have been shown to have little influence on the outcome of treatment. Placebo, Hope, & Expectancy factors 15% Reflect changes that occur simply because the client is in treatment of some kind “This class of therapeutic factors refers to the portion of improvement deriving from clients’ knowledge of being treated and assessment of the credibility of the therapy’s rationale and related techniques” Client / extra-therapeutic factors 40% Common factors: Mediate client change in therapy and are unrelated to techniques of the specific treatment approach Common factors argument: It is not the approach specific techniques that are operative in creating change, but the common elements shared by all approaches...... The therapeutic alliance (Responsible for most change) Monitoring the alliance Formal or informal The Working Alliance Inventory Session Rating Scale, Outcome Rating Scale Talkingcure.com Track the relationship, notice how the client responds (engagement, empathic failures, attendance, guardedness) Therapy Ruptures OARS The OARS Model: Open Ended Questions Affirmations Reflections Summary statements Example: Affirmations   That you see the person’s point of view The struggles or difficulties involved The success the client has had The skills/strength you perceive Practice QUESTIONS Questions can be used to Stimulate talk Restrict talk Show interest Pressure clients Ignore clients viewpoint Gather information Types of questions Open questions How, what Closed questions Who, where, when Swing questions Could, would, can, will Implied question I wonder…, It must… Guidelines for Questions Who is the question for, you or the client? Questions do not show you understand or are listening as well as reflection Recognise questions as an intervention or technique. Therapeutic Questions The Question “What would be different if you were well?” Four Big Reality Therapy Questions What do you want? What are you doing? Is it working? Should you make a new plan? Directive Interviewing techniques Used to encourage clients to change the way they think, feel and or act. Push clients Places responsibility on therapist to determine what client’s life, attitude or behaviour. Even when working collaboratively, therapist is deciding what advice and when to offer it. Should only be used when clients are ready to change Motivational interviewing Probably the most widely used approach in counselling for addictions Collaborative person-centred form of guiding to elicit and strengthen a persons motivation for change Always rooted in Rogerian approach Always person-centred Always a collaborative style Always focused on enlisting the persons own reasons for change Ambivalence is normal: If we push people one way, they will go the other As people argue for one solution, they become more committed to it “I learn what I believe as I hear myself speak” Miller noticed that the more he confronted his clients, the more they denied having a problem Motivation is a product of the style of interaction adopted by the therapist (Miller, 1985) https://www.youtube.com/watch?v=cj1BDPBE6Wk The therapist plays an important role in eliciting client motivation Uses a client-centred approach to working with ambivalence, which assumes: That when a therapist takes responsibility for the ‘good’ arguments, the client is left with no choice but to defend the ‘bad’ argument. Resistance to change is therefore is an outcome from the therapists style of engaging with the client. Resistance is a product of the interpersonal relationship Clients are guided in a way that results in them being able to tell you why they should change Therapist elicits self-motivating statements from the client Client’s are responsible for decision making and change Express empathy Skilful reflective listening is essential – strongest link to outcome Avoid labelling and focus on behaviour, not the person Deepen clients awareness of advantages and disadvantages of change Acknowledge the reasons not to change – benefits of no change Highlight the areas of the client’s discomfort Contrast where they feel they are with where they want to be Let the client confront themselves Reinforce the client’s self-efficacy Reinforce all realistic, positive statements Find strengths from previous successes The client is responsible for choosing and carrying out personal change Helping clients challenge themselves Cognitions Mindsets Ways of thinking Behaviours Discrepancies between cognitions and behaviours Others’ behaviour and attitude toward and impact on client Pull to reassurance Why might this mean? How might compliments, expressing your approval, have a negative effect on the clients therapeutic process? Complimenting and reassurance should be considered a technique, to be used in moderation Directive listening behaviours Feeling validation Interpretive reflection of feelings Psychoanalytic Interpretations Reframing Confrontation Immediacy What needs to be challenged Failure to own problems/External locus of control Challenge clients to state their problems as solvable Faulty interpretations of self, critical experiences, behaviours and feelings Notice discrepancies Between verbal and non-verbal communication Between what they think and what other people say Between expressed values and actual behaviours Between what they are and what they wish to be Between what do say and what they do How to challenge invite clients to challenge themselves to change ways of thinking and acting At the right time (requires trust and rapport) With curiosity With respect Without judgement Collaboratively Exploring consequences of cognitions and behaviour Asking questions “Help me understand…” Role reversal and perspective taking Asking questions that highlight agency. e.g., What are you avoiding? What opportunities are you ignoring? What role do you play here? How do you influence what’s going on? What’s really going on? Week 4: Evidence based practice “Nonetheless, EBPP fails to be a tripartite model because it is defined by science alone. This paper aims at explaining why this conflation may have come about. It also shows why clinical expertise and patient preferences should be defined extra-scientifically.” Medical model = problem in YOU, treat the symptoms with the individual, right intervention then you wont have that diagnosis anymore Extra scientific = outside of science – not based on the evidence but using your expertise and empathy Ie think about their characteristics – culture, sexuality etc Self-disclosure – of lived in experience eg queer In research do the therapy in exactly the same way each time Issues with EBP Published literature reflects a bias in its origin, with the vast majority of psychological research reflecting “Western, educated, industrialised, rich and democratic populations”. Thus, most psychological theory, evidence, and practice guidance arises shows a bias to Western cultural constructions of knowledge. This leads to inappropriate procedures to be applied to other populations. The focus on choosing the right intervention based on scientific evidence, means little attention is paid to measuring the effectiveness of the intervention or explaining its use to the client, as its just assumed to be the most effective “based in evidence.” Lived experience is often not included in the development or delivery of intervention. Lack of consideration of client factors, social factors and clinical expertise. Practice based evidence PBE more frequently encompasses environmental, community, social, and cultural factors that impact upon how people perceive and evaluate information (Dudgeon et al., 2021) than does EBP. This process allows for the client to be actively involved in the treatment decisions that will directly affect them (Dudgeon et al., 2021). This is now widely recommended for all research programs; for example, the NHMRC encourages the inclusion of people with lived experience in all stages of project design and execution. PBE has been recommended for research with Aboriginal and Torres Strait Islander peoples and other minority populations who can be marginalised by the dominant psychological perspectives and practices (Dudgeon et al., 2021). Implementation of EBP Defining the question with client/group. Conducting a thorough search of the literature, including literature specific to the client’s social and cultural orientation. Critically appraising the quality of the literature, relevant gaps in the evidence base, and evidence arising from other sources including PBE. Selecting an intervention, taking into consideration one’s own expertise and competence at administering the practice, and the individual characteristics of the client. Evaluating outcomes following the practice and monitoring progress, adjusting approaches as indicated by the evaluation outcomes. Ensuring outcomes are meaningful from the perspectives of the individual/group/organisation. The process is cyclical, moving back and forth between these steps. Week 4: Person-Centred Counselling Cark Rogers 1950’s humanism Humansitic reaction to what has gone before Reaction to: man as a product of his conflicted psyche Reaction to: the emphasis on the expression of sexual and aggressive impulses Reaction to: notions of determinism (you have no choice as to what you will become) Reaction to: only that which is observable is worthwhile (spirituality also worthwhile) Reaction to: the “therapist as expert” Development of PCA 1940s: Non-directive counselling (rogers questioning) Permissive, accepting climate; challenges assumption that the therapist knows best Omitted diagnoses; questioned use of advice, suggestion, teaching, interpretation Focus on reflecting and clarifying clients’ verbal/non-verbal communications 1950s: Client-centred therapy Best way to understand others’ behaviour, is from their own internal frame of reference Actualising tendency basic motivational force leading to change 1960s: Becoming the self that one truly is: Openness to experience; trust in one’s experience Internal locus of evaluation; willingness to be ‘in process’ Research and application to education (student-centred) 1970s-80s: Expansion / Person-centred approach Research and education Conflict resolution, leadership, health care, cross-cultural, international relations Politics and the search for world peace Key features: beliefs about people People are basically trustworthy with vast potential for understanding and resolving own problems Formative tendency All life forms have tendency to evolve into more complex forms Universe is constantly expanding – person has tend to become more complex Self-actualising tendency Humans have tendency to move towards fulfilment of our individual potential Source of psychological growth and maturity lie within us Mental illness result from a distortion in self-actualisation Organismic valuing People have an innate sense of what they need. When we are hungry, we find food that tastes good. Food that tastes bad is likely to be spoiled, rotten, unhealthy. Not based on oughts or shoulds / social pressures Conditions of worth As children, we learn that there are certain things we do that please our parents or caregivers, and we strive to do those things. Conditions we think we must meet in order for other people to accept us as worthy of their love or positive regard. Key features – client attributes Self-concept Perceptions and Feelings about Self Positive vs. Negative self regard Congruence of self Rogers Core conditions 1. Congruence Being true to oneself – “No student…can be trained to become client centred therapist. Being true to own experiences is far more important than coinciding with a therapeutic orientation” (Rogers, 1951, p. 433) Looks like: transparency, genuineness, relaxed openness Communicates: Authenticity 2. Unconditional Positive Regard Warm appreciation Respect “Prizing” of client Acceptance of client’s thoughts, feelings, wishes, intentions, theories, attribution of meaning Deepens with understanding of client Looks like: “no judgement” Communicates: Valuing of client as a person 3. Empathic understanding of the client’s frame of reference Seeing things “through the client’s eyes” Understanding the client’s perspective Looks like: genuine interest in the person Communicates: Belief in the client as a logical, organised being who directs behaviour toward perceived needs (although not always effectively) Key features: mechanisms for change People vary in the extent to which they can access their inner subjective content. By carefully listening and attending to a client’s narrative, it becomes validated and strengthened – thus improving the person’s access to their inner subjective world Psychological maladjustment and adjustment (Rogers, 1951) I become mentally unwell when I deny or distort my experience. I deny who I am and my sense of self is disorganized. I become well adjusted when my concept of self is consistent with my experiences My concept of “me” is consistent, organised but yet dynamic; it’s the result of interaction with everything around me, particularly the evaluations of me, made by others We experience emotion which also helps us meet our needs; the more important the need, the greater the intensity of emotion Experiencing (flexible vs. rigid) When I have experiences that don’t fit with my sense of myself or my view of the world, I might find them threatening. The more I am threatened, the more control I will try to have to maintain my sense of myself or my view of the world. When I am in an environment that is completely nonthreatening, I am able to face things that challenge my sense of myself or my view of the world, and adjust both to accommodate those experiences Therapist seeks to understand the client’s world – as far as the client is willing to allow it Therapist helps the client address feelings, closer in touch with own experience The tendency towards self-actualisation is intrinsic If the client can be put into a position where conditions of self worth are removed, they should naturally reintegrate themselves (“bandage on wound” analogy) ‘Resolution of self’ Understand discrepancy between the person we see ourselves as, versus the person we want to become Gain greater understanding of ourselves (feelings, uncertainties; hopelessness; threatening aspects of ourselves) Coming to terms with ourselves leads to congruence, and the resolution of vulnerability and anxiety Psychoanalysis: Therapist’s role Person-centred: Client’s role Key features Process Therapist helps the client address feelings, closer in touch with own experience Usually does not involve advice giving or reassurance these may indicate our lack of belief in the client’s capacity to be their own healer Involves intentional “non-directiveness” Evidence “Common Factors” research All therapies are successful, lack of significant difference between therapies. Perhaps it’s what’s common to them, rather than what’s different that makes them successful i.e., Therapist Characteristics (Roger’s Core Conditions) Week 4: EBPP and Carl Rogers Week 5: CBT REBT Rational Emotive Behaviour Therapy Albert Ellis (1913 – 2007) Originally trained in psychoanalysis Study of semantics led to a shift in thinking Founding father of cognitive behavioural therapies – 1950’s Dedicated life to field of psychology Originally coined “Rational Therapy” According to this approach, emotional disturbance is the product of irrational beliefs In order to improve functioning, rational beliefs need to be developed Irrational vs. Rational Beliefs Irrational beliefs Rigid Extreme False Not sensible Unconstructive Rational beliefs Flexible Non-extreme True Sensible Constructive Types of irrational beliefs Musts/shoulds Awfulising Low frustration tolerance (“I can’t stand this!”) Generalising/polarising (always/never, all or nothing) Lead to unhealthy & self-defeating emotions Horrified u Terrified u Panicked u Depressed u Self-hating u Self-pitying I Core musts Three core maladaptive “musts”: I must do well and win the approval of others People must treat me fairly, considerately and kindly and if they don’t they are no good and deserved to be punished I must get want I want when I want it; and must not get what I don’t want. It’s terrible if I don’t get what I want and I can’t stand i Ellis’ Common Irrational Beliefs It is a dire necessity for adult humans to be loved or approved by virtually every significant other person in their community. One absolutely must be competent, adequate and achieving in all important respects or else one is an inadequate, worthless person. People absolutely must act considerately and fairly & they are damnable villains if they do not. They are their bad acts. It is awful and terrible when things are not the way one would very much like them to be. Emotional disturbance is mainly externally caused and people have little or no ability to increase or decrease their dysfunctional feelings and behaviours. If something is or may be dangerous or fearsome, then one should be constantly and excessively concerned about it and should keep dwelling on the possibility of it occurring. One cannot and must not face life's responsibilities and difficulties and it is easier to avoid them. One must be quite dependent on others One's past history is an all-important determiner of one's present behaviour and because something once strongly affected one's life, it should indefinitely have a similar effect. Other people's disturbances are horrible and one must feel upset about them. There is invariably a right, precise and perfect solution to human problems and it is awful if this perfect solution is not found C = Consequences Consequences of the belief * Emotional * Behavioural * Cognitive Emotional consequences Emotions central part of CBT – emotional responses are heavily moderated by our cognitions Emotional consequences People will experience negative emotions It’s ok to feel negative emotions if the situation warrants REBT differentiates between healthy and unhealthy negative emotions Irrational beliefs will result in negative/unhealthy emotional consequences Unhealthy Negative Emotions Anxiety Depression Guilt Shame Unhealthy anger Hurt Unhealthy jealousy Unhealthy envy Healthy Negative Emotions Concern Sadness u Remorse Disappointment Healthy anger Sorrow Healthy Jealousy Healthy envy Behavioural consequences Behavioural consequences include: Overt behaviours Impulses – not expressed behaviourally Suppressed impulses give insight into a person’s irrational beliefs, even if they behave in a rational way E.g. Greg’s boss criticizes his work Overt behaviour: thanks boss for feedback u Suppressed impulse: punch him in the face u The suppressed impulse provides insight into Greg’s irrational beliefs Cognitive Consequences Consequences can present in cognitive processes Cognitive distortions can arise from the irrational beliefs and unhealthy emotional consequences Reinforce distorted beliefs or “rules” REBT: Treatment We have the capacity to change our cognitive, emotive & behavioural processes Difficult - it takes work Not “positive thinking” Requires an active, directive & highly cognitive approach Therapist’s Function & Role Show clients how they have incorporated irrational beliefs ­ Show clients how they are keeping their emotional disturbances active by continuing to think irrationally ­ Help clients to modify their thinking & minimise their irrational ideas ­ Challenge clients to develop a rational philosophy of life ­ Rapport & empathy are important, but ‘too much warmth’ can be counterproductive Therapeutic Techniques & Procedures Cognitive Methods Disputation Detecting and debating distortions Why must you get what you want? u Where is it written that other people must treat you fairly? u Just because you want something, why must you have it? Cognitive homework Changing language/reframing Emotive Methods Rational Emotive Imagery Humour Role playing Rational Emotive Imagery 1. Imagine, vividly and clearly, the event or situation with which you have trouble. 2. Allow yourself to feel - strongly - the self-defeating emotion which follows. 3. Note the thoughts creating that emotion. 4. Force the emotion to change to a more functional (but realistic) feeling. It is possible to do this, even though briefly. 5. Note the thoughts you used to change the emotion. 6. Practice the technique daily for a while Rational Humour WHINE, WHINE, WHINE! I cannot have all of my wishes filled Whine, whine, whine! I cannot have every frustration stilled Whine, whine, whine! Life really owes me the things that I miss, Fate has to grant me eternal bliss! And since I must settle for less than this Whine, whine, whine! Role playing Test out and practice different statements, responses, coping modes Often used when the situation involves communicating with other people Can do it solo (e.g. in front of mirror), but role-playing with someone else is more effective + can receive feedback Behavioural Methods Relaxation techniques Breathing Mindfulness exercises Exposure Deliberate, planned, used in conjunction with cognitive skills u Shame attacking exercises Shame attacking exercises Behavioural experiments designed to forcefully and directly challenge a sense of shame, a desire to conform to social standards and our need for the approval of others. Classic Ellis Examples: Repeatedly stop a bus without getting off “Walk” a banana down the street (!) Ride a crowded elevator standing backward (facing the rear) Find a restaurant that offers “two eggs any style” and ask your waiter for one fried and one scrambled Applications and limitations Applications ­ Broad based: clinical and non-clinical problems ­ Mild to moderately severe mental disorders ­ Anger & aggression, sexual difficulties, unassertiveness ­ Individual & group settings ­ Couples and family therapy Limitations ­ Intense work ­ Emphasis on cognitive restructuring ­ Client suitability ­ Lack of focus on the past ­ Pressure on clients ­ Overemphasis on rationality ­ Cultural considerations ­ Therapist style ­ Not strengths-based ABC theory & treatment Cognitive therapy & CBT goal of CBT is to change maladaptive ways of thinking and acting in order to improve psychological well-being. What is CBT? A type of psychotherapy that helps people to change unhelpful or unhealthy thinking habits, feelings and behaviours. A relatively short term, focused approach to the treatment of many types of emotional, behavioural and psychiatric problems. streams of negative thoughts that seemed to appear spontaneously (also called assumptions) Beck called these cognitions automatic thoughts. These thoughts are based on general, overarching core beliefs, called schemas (or schemata) that the person has about oneself, the world, and the future. Ellis called self-statements Not limited to changing thinking & behaviours – emotional responses strongly moderated by our cognitions General approach Cognitions strongly influence behavioural and emotional responses Modify cognitive distortions – reduce emotional distress & maladaptive behaviours Identify test validity replace Focus on here and now Collaboration between therapist & client Is not replacing negative thoughts with positive Not about denying rational negative – ie grief automatic thoughts reported by patients with emotional problems are associated with thinking patterns that lead to probability overestimation. This term refers to the cognitive error that occurs when a person believes that an unlikely event is likely to happen. Catastrophic thinking Alternative ways of thinking then putting to the test ie talk to someone ou don’t know Thinking habitual so hard to change Initiating and maintaining factors are different Knowing initiating not enough to fix the problem, also many people have same issues but not all develop psychological problems Exception is PTSD where initiating is directly related to development Whether a stressor leads to psychological problems is down to the vulnerability of the person (diathesis-stress model) Acknowledges culture contributes to the expression of a disorder, but disagree that human suffering is simply a made up construction by society Acknowledge biological substrates, not think its not enough Meds + CBT not particularly effective, placebo as effective Aaron Beck Background 1921 –1960’s University of Pennsylvania Psychoanalysis Depression & automatic thoughts Self-report inventories BDI & BAI Beck & Ellis did not collaborate but approaches are very similar Basic premise of cognitive therapy Levels of cognition Negative automatic thoughts Automatic Tend not to realise their influence Taken as true The early focus of therapy – more available to conscious mind Identity and modify cognitive distortions to reduce emotional distress and behavioural problems Test validity of their thoughts and substitute with more adaptive thoughts Categories of cognitive biases Extreme Thinking Dichotomous thinking (black/white) I did that really badly. I might as well not bother at all If I don’t get an “A” on this test, then I’m a real failure If I don’t get it all done, then I may as well not start it Unrealistic expectations/high standards He should have called me earlier I must get full marks Catastrophising (what if…?!) What if I make a fool of myself and people laugh at me? I won’t be able to stand it. I didn’t get all my work done – I’ll get the sack What if I haven’t turned the iron off and the house burns down Selective Attention Over-generalisation She let me down, I can never trust anyone Mental filter That was a terrible day. It would have been good if I hadn’t tripped on the pavement and embarrassed myself. I have such horrible legs. I’m really unattractive. Disqualifying the positive He is only saying that to be nice That was a small achievement but others do better Yes, I got a raise, but it wasn’t very big and I’m still not very good at my job Magnification and minimisation What a mess I made of that deal Yes I got the terms that my boss wanted but I didn’t handle it well Relying on Intuition Jumping to conclusions Mind reading I can tell he hates my shirt I haven’t spoken to him since the party. He must have thought I was weird. Fortune telling - It’s not going to work out so there’s not much point trying. This relationship is sure to fail. Emotional reasoning I feel ugly, therefore I must be ugly I feel hopeless therefore my situation must be hopeless Self-reproach Taking things personally They’re in an awful mood. It must have been something I’ve done. I think they had a bad time because I burnt the dinner. Self-blame/self-criticism I feel sick, I must have brought it upon myself Name-calling I’m an idiot Negative automatic thoughts Evaluating the extent to which a thought is believed is an important starting point If a thought is only believed at a rating of 20%, then there is little use in working through this thought The likelihood of high-level distress in connection to the thought is very low, and so little value will be gained from the exercise since the starting point is manageable anyway If the thought is relatively emotion-laden and creating distress, then this is a good place to start Dysfunctional assumptions Dysfunctional assumptions can be thought of as unhelpful rules or expectations by which we live by. Often sound like ‘if/then’ statements “If someone who knows me doesn’t say hello as I pass them in the street then they dislike me” “If I try hard and don’t succeed then I’m a loser” “People will think less of me if I’m depressed” “I must get everyone’s approval” “I must stay in control otherwise I’ll be overwhelmed” “If I try I’ll fail” Not as easy to identify as NATs Develop as a way of protecting against negative core beliefs Can be culturally reinforced Rigid Focus later in therapy to prevent relapse Core beliefs Automatic thoughts, problematic affect and unhelpful behaviours are driven by core beliefs Embedded templates about ourselves, others and the world Common unhealthy core beliefs include: I am worthless I am unlovable I am inadequate Core beliefs are: Not easily accessible and often operate outside a person’s awareness Absolute statements that seem true to the person in all situations Learned in early life but can also be modified by other life experiences (e.g. trauma) Not always targeted in short-term CBT Identifying core beliefs Spontaneously reported during session Downward arrow Why would that be so bad? What would be the worst thing that could happen? And if that were true – then what? If that happened what would it say about you? What would that say about your future? Beck’s CT vs Ellis REBT Different terminology REBT: therapist is teacher CT: higher importance of therapeutic relationship, not as forceful or confrontational CT is less confrontational than REBT REBT: method depends on personality CT: method depends on disorder Socratic Questioning What is Socratic Questioning? Socrates: Greek philosopher around 400BC Unique questioning approach to encourage students to arrive at own answer Gain knowledge through critical thinking Cornerstone of Cognitive Therapy When to use SQ Assessment and formulation Education Questioning unhelpful cognitions Problem-solving and working out solutions Devising behavioural tests Assessment & formation Identify cognitions, sensations and behaviours relevant to presenting problems Clarify feelings and thoughts What did you do when that happened? What did it mean to you when you thought/did that? When was the first time that this thought occurred to you? Did you have any other feelings? What goes through your mind when you feel like that? What do you tend to do at those times? Education Link between thoughts, feelings and behaviour can be explored collaboratively using SQ Hypothetical scenario – imagine the consequences of different thoughts E.g. belief dogs were dangerous vs. belief that dogs were cuddly and safe Questioning unhelpful cognitions Consider possibilities outside of current perspective Several types of questions: “Evidence for” “Evidence against” u “Alternative view” u “Consequences of” Evidence for.. Build up balanced view of situation Reduce self-criticism Why might any of us have that thought at some time? In your experience, what fits with this belief, what makes it seem true? Evidence against… Direct client’s attention to experiences that provide alternative possibilities Do you have any experiences of this not being the case? Is there anything that doesn’t fit with that thought? How might someone else view that situation? Is that so all of the time, or are there occasions when things are different? Alternative view After understanding why they hold a belief, clients can explore alternative possibilities: Now that you’ve looked at the bigger picture, how would you view your original concern? Given what you’ve just described, how likely do you think it is that the worst will happen? Consequences of Explore pros and cons of beliefs Can motivate client to change How helpful, or unhelpful, is it to hold this particular belief? What good, if any, comes of holding this belief? What is the downside of seeing things this way? If you see the world this way, how do you feel, how do others react? Problem solving Define problem + brainstorm solutions: So, just what is it that you fear will happen? How might your friend try to deal with such a dilemma? Given that you have identified avoidance as an obstacle to gaining confidence, how would you advise a friend to go about dealing with this obstacle? Contingency planning: What is the worst-case scenario if this solution does not work? How could you prepare for that? How might you guard against it happening? What could you do if it did happen? Devising behavioural tests Elicit rationale What do you think would happen if you held your ground and did not run away? u What would go through your mind? u And if you were able to remain in the situation, what would go through your mind? u How would you feel? What would his mean to you? Shape experiment: How might we set up a situation where this could happen? What would make it easier for you to take on this challenge? How will you gauge your success? Trouble shoot What could go wrong? How might you prepare yourself/deal with this if it happened? What would we learn from that? Attitude of SQ Gentle inquiry + genuine curiosity Padesky (1993): Changing minds vs. guided discovery Consider the difference between the attitude of “you are wrong” vs. “there are other possibilities” Stages in SQ Concrete How long have you felt low in your mood? How often do you binge? Empathic Listening Summarising You say that you have felt depressed for the past 3 months, but that for several years you have felt rather low Synthesising/Analysing When we review the past few years, your lowest point seem to be: X, Y and Z. If there anything that links these events? Practicalities of CBT Time-efficient treatment 1–20 weekly 50-minute sessions Treatment often structured by manuals Bibliotherapy widely used Homework is expected Training is widely available Future Directions Fastest growing & most researched system Continued commitment to evaluation, integration, and short-term treatment Wider application to more disabling conditions, e.g. BPD, bipolar, and psychoses Popularity and evaluation of online CBT systems E-Mental Health in Practice u Mindspot u Brave u Blackdog Institute Week 6 ACT Western Psych health founded upon the assumption of healthy normality Given a healthy environment, lifestyle and social environment, humans will be happy and content Psychological suffering is seen as abnormal ACT believes this assumption of healthy normality to be false High standard of living yet high level of psychological suffering Large numbers of population with psychiatric disorders Addictions Suicide Loneliness Low self-esteem Existential angst ….. Behavioural therapy – action guided by values ACT came from RFT (relational frame therapy) Part of third wave (DBT, FAP, MBCT, CFT, ACT) Is nonlinear – gives flexibility but harder to learn “the steps” May not be suitable where a person has no language, TBI, extreme autism Aim of ACT Aim of ACT = increase one’s ability for mindful, values guided action = psychological flexibility Max human potential while effectively handling the pain that inevitably goes with it Pain can be the experience of Also pain from our own mind Life is difficult A full human life comes with the full range of emotions – pleasant & painful A normal human mind naturally amplifies psych suffering Destructive v Healthy Normality ACT assumes that the psychological processes of a normal human mind are often destructive Create psychological suffering for all of us sooner or later Postulates that root of suffering is human language itself Language includes words, images, sounds, facial expressions and physical gestures Private Language (Cognition) • Thinking • Imagining • Daydreaming • Planning • Visualising Public Language • Speaking • Talking • Miming •Gesturing • Writing • Painting • Singing • Dancing Mind as a metaphor for language The mind is a complex set of cognitive processes that rely upon human language Analyzing, Comparing, Evaluating, Planning, Remembering, Visualising The word ‘mind’ in ACT is used as a metaphor for language itself 6 Core Pathological Processes = Psychological Inflexibility Cognitive Fusion Cognitions dominate our behaviour (overt or covert) in a manner that is self-defeating or problematic Dominate our physical actions (no one likes me = not going to social event) Dominate our awareness – are no longer paying attention to the things we should ie work Fuse with cognition can look like: Something we must obey A threat we must avoid/ get rid of Something so important it requires all of our attention Being entangled by thoughts Attention is on content of thoughts Actions are made based on internal experience In a state of fusion, a thought can seem like: Thoughts are reality: as if what we are thinking is actually happening Thoughts are the truth: we totally believe them Thoughts are important: we treat them seriously, giving them our full attention Thoughts are orders: we automatically obey them Thoughts are wise: we assume they know best and we follow their advice Thoughts are threats: we let them frighten or disturb us 6 categories of fusion Fusion with the past Rumination/ regret Blame/ resentment of past events Idealising the past Fusion with the future Worry/ catastrophising Predicting the worst/ hopelessness Anticipating failure/ hurt/ rejection Fusion with self-concept Negative self judgement Positive “I am better than…” Overidentifying with label “I am depressed” Fusion with reasons I am too.. X might happen Pointless too hard I am X (a loser) X says I shouldn’t (religion, parents etc) Fusion with rules Past and future Self and others Own thoughts/ feelings Our body/ behaviour/ life The world places people events etc Fusion gives rise to experiential avoidance Hooked = both Eg drinking to avoid anxiety I need a beer Automatic mode = in a state of fusion we do whatever our thoughts tell us to Avoidance mode = in a state of fusion we do whatever we can to avoid/ get rid of feelings and thoughts Attachment to the Conceptualized Self Extreme form of fusion – fusion with one’s entire self concept Over-investment in self-perception (i.e. self conceptualisation) Rigid behaviours aimed at validating or defending one’s stories (self-fulfilling prophecy) Self as content Experiential Avoidance Attempts to escape from or avoid “unpleasant” thoughts, feelings, memories, physical sensations and other internal experiences Maintained through short-term negative reinforcement Habitual and persistent unwillingness to experience uncomfortable thoughts and feelings keep problems going These things not the problem, but our reaction to them is the problem Avoidant behaviour eg social media, food etc Eg anxious socially = I won’t go = social phobia Also not gritting teeth and doing it = tolerance, not acceptance Effort & energy the difference Suppression of thoughts been shown to Rebound effect – increase intensity and frequency Suppressing a mood can amplify it Associated with psychopathologies eg AD, depression, BPD also higher higher risk behaviour, substance abuse etc Not about avoiding everything – if it assists you living values then go for it Disconnection From Present Moment People who are “living in their heads” (past [hopelessness/ helplessness] &/or future [rumination]) Not about being present oment all of the time, using past and future thinking positively eg for problem planning, etc. Not for stuckness. Not in contact with what is going on in the present moment. Focus is on remembering and/or anticipating painful events Not all or nothing, if podcasting because its good for you versus colluding with avoidance Lack of Values Clarity/Contact Client in psychological pain and often not in touch with their values Values provide direction for action Unclear values = feeling stuck Habitual behaviour an example Unworkable Action Behaviours that pull away from mindful, valued living e.g. addiction Action that keeps people “stuck” in patterns that are self-defeating or self-destructive Fused with what is going on in their minds Sources = unclear values, experiential avoidance Is that working for you? How does it work in the long run if you let that rule life, dictate actions Hooked on these thoughts doe sit help you get the things that you want If you let those thoughts guide you does it help you to be the person you want to be? Woud you like to change that? Six core pathological processes of psychological rigidity Fusion Experiential avoidance Remoteness from values – they get lost in fusion & exp avoid Unworkable action – impulsive, reactive, automatic instead of mindful or purposeful Fusion with self concept Inflexible attention Distractibility – difficult sustaining attention on task at hand- easily shift stimuli Disengagement – lose conscious contact/ interest in experience (autopilot, bored etc) Disconnection - lack of contact with our thoughts/ feelings 6 Core Therapeutic Processes = Psychological Flexibility ACT hexoflex Psychological flexibility “…the ability to contact the present moment more fully as a conscious human being and to change or persist in behavior when doing so serves valued ends.” (Hayes et al., 2005) In everyday language, this means holding our own thoughts and emotions a bit more lightly and acting on longer term values rather than short term impulses, thoughts and feelings. Measured by the AAQ-II https://stevenchayes.com/wpcontent/uploads/2023/01/The-Acceptance-and-ActionQuestionnaire.pdf ACT Triflex Defusion (watch your thinking) / cognitive defusion “Taking a step back” from thoughts Alter undesirable function of thoughts and other private events (rather than trying to alter form or frequency) Dozens of techniques to help with this! All distancing ie screen saver, thoughts on a bus, leaves on a tree CBT change the thought – ACT is about “yeah you are having the thought”. Just observing the thoughts from a distance Result = decrease in believability or attachment to thoughts Self as Context (pure awareness) One can be aware of the flow of experiences without attachment to them Fostered by mindfulness exercises, met