PL3257 Notes PDF

Table of Contents Week 1 - Lecture 1: Introduction..............................................................................................................5 The Clinical Golden Chain..................................................................................................................... 5 Referral sources:................................................................................................................................... 5 Part 1 - Assessment.............................................................................................................................. 5 Generic formulation model: 4Ps............................................................................................................ 8 Behavioural theory.................................................................................................................................8 Cognitive behavioral therapy................................................................................................................. 9 Part 2 - Formulation: General principles.............................................................................................. 10 Week 1 - Reading: Chapter 1: What does a clinical psychologist do?...............................................11 Assessment......................................................................................................................................... 11 Formulation.......................................................................................................................................... 11 Intervention.......................................................................................................................................... 11 Evaluation............................................................................................................................................ 11 Multi-disciplinary team (MDT).............................................................................................................. 11 Reflective practice................................................................................................................................11 Week 2 - Lecture 1................................................................................................................................... 12 Part 3 - Communication....................................................................................................................... 12 Part 4 – Behavioral Intervention.......................................................................................................... 12 Part 5. Evaluation, General Principles.................................................................................................14 Where do clinical psychologists work?................................................................................................ 14 Case study...........................................................................................................................................16 Roles of a Clinical Psychologist...........................................................................................................16 Roles of a more senior clinical psychologist........................................................................................17 Professionals in the service................................................................................................................. 17 Scientist-Practitioner............................................................................................................................17 Evidence-Based Practice.................................................................................................................... 18 Reflective-practitioner.......................................................................................................................... 18 Reflective practice: Step 1 – Deconstruction.......................................................................................18 Reflective practice: Step 2 – Reconstruction.......................................................................................19 Week 2 - Reading: Chapter 2: The Art and Science of Psychological Practice.................................20 The Scientist-practitioner..................................................................................................................... 20 The Reflective Practitioner.................................................................................................................. 20 The Critical Practitioner....................................................................................................................... 20 3 frameworks in clinical practice.......................................................................................................... 20 Behavior Therapy................................................................................................................................ 20 Cognitive-behavioral therapy (CBT).................................................................................................... 20 Psychodynamic therapy...................................................................................................................... 21 Systemic therapy................................................................................................................................. 21 Week 2 - Reading: Chapter 3 - Working in Teams................................................................................ 21 Introduction to professional roles within mental health........................................................................21 Different perspectives brought to the understanding of human distress............................................. 21 A clinical psychologist’s role in multi-disciplinary teams...................................................................... 21 Week 3 - Tutorial 1: Readings and Class...............................................................................................22 Rapport Building - Helpful....................................................................................................................22 Rapport Building - Unhelpful................................................................................................................22 Non-verbal - Helpful.............................................................................................................................23 Verbal - Helpful.................................................................................................................................... 23 Verbal - Unhelpful................................................................................................................................ 24 Active Listening................................................................................................................................... 24 Week 3: Chapter 5: Beginning Conversational Skills: Joining and Maintaining an Interview......... 25 Joining skills........................................................................................................................................ 25 Basic Conversational Skills................................................................................................................. 25 Week 3: Chapter 6 – Basic Reflecting Skills - Exploring Client Content............................................26 Issue Cycle.......................................................................................................................................... 26 Exploring content................................................................................................................................. 26 Week 3 - Lecture 3: Working with Children and Families.................................................................... 27 Systemic Practice................................................................................................................................ 27 Circular questioning............................................................................................................................. 27 Further factors for consideration:.........................................................................................................28 Systemic formulations......................................................................................................................... 29 Part 1. Parent coaching: Managing behavior...................................................................................... 29 Reflective parenting: Attachment-focused...........................................................................................30 The Parent Map - what parents bring to the relationship.....................................................................31 Week 3 - Reading: Chapter 4 - Working with children and young people..........................................33 Normal childhood development and its pitfall...................................................................................... 33 What psychological difficulties can occur for children and young people............................................ 33 Diagnosis............................................................................................................................................. 33 Aetiology.............................................................................................................................................. 33 Psychological help for children and young people.............................................................................. 33 The use of theory and evidence in psychological practice.................................................................. 33 Communication and creative in working with children.........................................................................33 Critical issues...................................................................................................................................... 33 Week 4 - Lecture 4: School observations............................................................................................. 34 Setting the Stage................................................................................................................................. 34 Interview Schedule with Teacher......................................................................................................... 34 Formal Psychological Tests................................................................................................................. 34 Defining Learning (Intellectual) Disabilities – DSM5............................................................................34 Assessment of Intellectual Functioning............................................................................................... 35 Features of Psychological Tests.......................................................................................................... 35 Consideration of Results in Context.................................................................................................... 36 Cognitive tests in context.....................................................................................................................36 Sample adaptive functioning – CI interval and Clinical judgement......................................................37 Why use questionnaires in assessments?.......................................................................................... 37 Questionnaires for treatment evaluation..............................................................................................40 Types of Questionnaires...................................................................................................................... 40 Purpose of questionnaires...................................................................................................................40 Assessing progress in therapy............................................................................................................ 41 Assessing Therapeutic Alliance...........................................................................................................42 Setting the stage for School Observations.......................................................................................... 42 Week 4 - Reading: Chapter 5 - Working with Families......................................................................... 45 Systemic practice................................................................................................................................ 45 Help for families: family needs and service responses........................................................................45 Use of theory and evidence in practice............................................................................................... 45 Critical issues...................................................................................................................................... 45 Week 5 - Lecture 5: Working with Individuals with Anxiety................................................................ 46 Behavioural Theories of Anxiety – FIRST Wave................................................................................. 46 Cognitive Theories of Anxiety – SECOND Wave................................................................................ 46 Anxiety-Specific Cognitive Vulnerabilities............................................................................................46 Therapy Targets – Thoughts and Behaviours (Responses)................................................................ 47 Therapy Targets – Behaviours.............................................................................................................47 Formulation (CBT)............................................................................................................................... 48 Evidence-based practice: NICE guidelines......................................................................................... 49 Psychoeducation about anxiety...........................................................................................................49 Behavioural experiment: Self-focus attention...................................................................................... 49 Cognitive intervention: Video feedback............................................................................................... 50 Behavioural experiment: Exposure outside the clinic.......................................................................... 51 Week 5 - Reading: Chapter 7 - Working with Anxiety Disorders.........................................................53 Types of psychological difficulties that may occur in anxiety disorders............................................... 53 - DIAGNOSIS...................................................................................................................................... 53 Epidemiology....................................................................................................................................... 53 Aetiology.............................................................................................................................................. 53 Factors.................................................................................................................................................53 Theory and evidence for psychological intervention............................................................................53 Team working/indirect work................................................................................................................. 53 Critical issues...................................................................................................................................... 53 Treatment models for main anxiety disorders......................................................................................53 Week 5 - Tutorial 2: Readings and Class...............................................................................................54 Normalisation Competency - Helpful................................................................................................... 54 Normalisation Competency - Unhelpful............................................................................................... 54 Empathy Competency - Helpful........................................................................................................... 54 Empathy Competency - Unhelpful.......................................................................................................55 Week 5: Chapter 2: The Therapy Client - Motivation and Understanding of Therapy...................... 55 Definition of person coming to therapy................................................................................................ 55 Motivation for therapy.......................................................................................................................... 55 Help-seeking behaviour.......................................................................................................................55 Media presentation of therapy............................................................................................................. 56 Societal view of those who seek therapy.............................................................................................56 Opening up in the first session............................................................................................................ 56 The client’s experience in therapy....................................................................................................... 56 Readiness for change..........................................................................................................................56 Week 5: Chapter 7: Advanced Reflected Skills: Exploring Client Feelings and Meanings.............. 56 Defining Empathy................................................................................................................................ 56 Curiosity...............................................................................................................................................56 Content and feelings............................................................................................................................56 Designing Reflections.......................................................................................................................... 56 Responding with Reflections............................................................................................................... 56 Ownership of feelings.......................................................................................................................... 56 Reflections........................................................................................................................................... 56 Paraphrase or Reflection..................................................................................................................... 56 Reflection of nonverbal feelings.......................................................................................................... 56 Keeping the focus on the client........................................................................................................... 57 Focusing.............................................................................................................................................. 57 Reflection of meaning.......................................................................................................................... 57 Week 6 - Lecture 6: Working with Individuals with Depression..........................................................58 Theory 1: Learning.............................................................................................................................. 58 Theory 2: Attribution Style Theory....................................................................................................... 58 Theory 3:Cognitive Theory.................................................................................................................. 58 Theory 4: Ruminative Response Style (Behaviour).............................................................................58 Theory 5: Metacognitive Awareness....................................................................................................59 What to do in therapy.......................................................................................................................... 59 CBT (Westbrook Depressive Cycle).................................................................................................... 59 1. Behavioural activation..................................................................................................................... 60 2. Cognitive restructuring.....................................................................................................................61 3. Behavioural experiments................................................................................................................. 62 Acceptance and Commitment Therapy (ACT).....................................................................................62 Sample Therapy Outline...................................................................................................................... 64 Creative hopelessness........................................................................................................................ 65 Traditional ACT Protocols....................................................................................................................65 Week 6 - Reading: Chapter 6 - Working with Depression....................................................................69 DIAGNOSIS.........................................................................................................................................69 Epidemiology....................................................................................................................................... 69 Aetiology.............................................................................................................................................. 69 Theories...............................................................................................................................................69 Theory and evidence for psychological interventions..........................................................................69 Case study...........................................................................................................................................69 Critical issues...................................................................................................................................... 69 Week 8 - Lecture 7: People with Borderline Personality Disorder and High Risk.............................70 (A) Borderline Personality Disorder..................................................................................................... 70 Treatment: NICE Guidelines................................................................................................................71 Biosocial Model................................................................................................................................... 71 (B) Dialectical Behavior Therapy......................................................................................................... 73 - Comprehensive DBT: 4 Modes of Treatment.................................................................................... 74 (C) Risk Assessment........................................................................................................................... 77 Assessing Suicidal risk levels.............................................................................................................. 78 What to do with the information........................................................................................................... 78 What goes into a crisis plan that clients bring home?......................................................................... 78 Week 3 - Lecture 3................................................................................................................................... 79 Week 3 - Lecture 3................................................................................................................................... 79 Week 3 - Lecture 3................................................................................................................................... 80 Week 3 - Lecture 3................................................................................................................................... 80 Week 3 - Lecture 3................................................................................................................................... 81 Week 3 - Lecture 3................................................................................................................................... 82 Week 1 - Lecture 1: Introduction 9 By the end of the lecture, you should be able to: 1. Describe the different aspects of the clinical golden chain 2. Identify broad generic categories of information to obtain during assessment 3. Apply the 4Ps model to formulate a client’s difficulties 4. Develop a preliminary understanding of how to formulate using different perspectives (behavioural and CBT) 5. Understand how assessment, formulation, communication, intervention, and evaluation relate to each other (e.g., how assessment informs formulation etc.) 11 The Clinical Golden Chain Get info → Formulate → Let the client know what is happening (get their buy-in) → therapy At any point in this chain, new info can surface (especially during the communication, intervention, and evaluation stage) → changing the way we view the formulation → might need to return to assessment Linear possess but at any point, we might revert back to the assessment stage 12 Always start with referrals Referral sources: - Self (common in private settings) - Parental consent is still needed for children - Family (common for children; could be spouse) - Colleague (e.g., general practitioners, psychiatrists, school teachers, social workers etc.) - School counsellors → encouraged to inform the parents to bring the child to psychologist instead of the psychologist ringing up the parents - Court-mandated 13-14 Part 1 - Assessment Before the assessment: - Reading existing reports, referral letters - However, flexibility is very important: - Referral could differ from the actual presentation/ clients’ concern - Do not fix the formulation based on referral only, keep an open mind - Consider relevant symptom profiles (DSM-5) - diagnostic criteria can be helpful to know what symptoms cluster together, but not how they developed or are maintained. - Consider relevant formulation models - Decide who to invite to the session - Children: usually the parent(s), caretaker - Adults: might not want another person in the session, ask for consent - Hypothesize what the possible problems could be Aims of an intake assessment: - Gather information - Kinds of info: difficulties (“what brings you here today”), why the difficulty is happening, what triggered it - Initial formulation - Identifying, evaluating, and exploring client’s difficulties and therapy goals - Obtaining information about client’s interpersonal style, interpersonal skills, and personal history - Difficult to ask/self-identify - This could be based on the psychologist’s interactions with the client, clinical observations - Infer from how the clients relate to people across time (eg. friendships, relationships → intense? fleeting?) - Understanding the client’s current life situation and functioning - Typically the issues implicate their functioning - Different domains of functioning in the client’s life: acads, friends. etc - Build rapport - Most people attend ONE session - Rapport is the biggest part to push through that ONE session Add. Example of referral letter: What information would you gather during the intake interview? 15-18 During the Assessment Session - Beginning the assessment - Introducing yourself and the duration of the meeting - Obtain informed consent - Explain confidentiality and its limits - The psychologist will decide how high risk is reportable → can the psychologist and client manage the risk - Creating a safe space with confidentiality - Risk of harm to self or others as the limit - Process vs Content Process - Building rapport with the client - Active listening - Attention to body language: eye contact, leaning forward, head nods etc. - Appropriate silences - Rephrasing/clarifying - Checking that you got it right Reflection of implicit feelings - Summarizing - Validation - Observing the client during the interview - E.g., eye contact, activity level, attention span, impulsivity, interaction styles, congruency between emotions and content, how do they speak (tone, volume, pace) - Possible incongruency → can be talking about something traumatic but they are smiling - Possible emotion suppression → not adaptive in the long term; problematic emotional regulation strategy - Just give you direction, not a diagnosis - Can use this to see if the client is reacting well to the therapy - Observe your own emotional reactions to the client - Reflective practitioner - How much of it is a clinically relevant situation or the psychologist's personal biases/belief 19 Content - Current concerns - Figure out who is the client - Particularly difficult in child cases - Medically/ in the system: the child is the client - But therapy-wise: it could be about the parents or the environment the child is in - Explore the presenting problem - The frequency, duration, and intensity of the problem - Eg. Happiness (normal) but extremely intense → Mania - Factors contributing to the difficulties → Where we usually start before reaching history - History - Family - Education - Medical/ development - For child cases, psychologists refer to this often - Eg. if the child has hearing difficulties, they might not have ADHD. it could be that it is difficult for them to focus because of the difficulty in hearing or the frustration that comes with it which causes them to tune out - Social/ forensic - Risk assessment - Thoughts and frequency; any current plan - Determine how high the risk is - Previous attempts; deliberate self-harm, - Identify protective factors - Previous intervention and perceptions of it - Looked for what worked and what didn’t work - Strengths and resources - Goal(s) for therapy - Shared and concrete - Eg. the Goal is to not feel anxious anymore → from an acceptance and commitment therapy perspective, it is called a dead man’s goal because we will never reach this There are personal, community, neighborhood, and family protective factors 20 21 Generic formulation model: 4Ps Problem definition - Current concerns and strategies of coping 1. Predisposing factors: History - Relevant life history or personality traits that increase vulnerability 2. Precipitating factors: Trigger - Get a sense of the history of the problem - What just happened? 3. Perpetuating factors - Explore what maintains the problem - Can look different depending on your treatment modality → Behaviour = looking at what reinforces behaviours - Perpetuating → beliefs, coping behaviours, meaning of symptoms 4. Protective factors - Strengths and resources 5. *PRESENTING CONCERN - What is the problem - Formulate according to this - Might change as well 22-23 Behavioural theory - “Functional analysis” → All behaviour has a purpose - The link between - Antecedent: triggering event(s) - Behaviours - Consequent: reinforcing event(s) - A triggers B - C reinforces B (based on operant conditioning principles) - Problematic behaviors (B) change by altering A or C - In therapy, we will target A or C - - Likely to target C → change what the parents do (there’s a process, can’t just tell them what to do), emotional regulation for the anxiety - A,B,C says nothing about 4Ps → all of these are perpetuating factors 24-25 Cognitive behavioral therapy - Based on the cognitive model - Unhelpful thinking/thinking error as common to psychological distress - If individuals could evaluate their thinking in a more adaptive way→improvement in emotions and behaviors - Help clients evaluate thinking via two major ways - Guided discovery for assessment and intervention - Behavioral experiments to test predictions - Core beliefs about self, others, and the future - Same event but different people can have different thoughts - Why do some children fear monsters under the bed after Monsters’ Inc but some dont - Intermediate beliefs – attitudes, rules, and assumptions - Triggering event - Vicious cycles - Automatic unhelpful thoughts - Emotions - Bodily sensations - Unhelpful behaviours - - Cog (thought content) influences the rest 26 - - Talk to the client about whether these thoughts are helpful + strategies to help with the body sensations + thought exercises (eg. “feel angry now!” → but we cannot → to prove that you can’t just summon an emotion of demand that you don't anxious anymore) 27 Part 2 - Formulation: General principles - Integrating the multiple sources of information gathered - Observation and self-report - Clients and the social system around the client - Map out the problem in a collaborative way - Hypothesize the development and maintenance of the problem - An iterative process - Formulation to guide intervention Week 1 - Reading: Chapter 1: What does a clinical psychologist do? 16 What a clinical psychologist does 17 Use of “clients” and “service-users 18-19 Referral information - Case file: Diagnosis, Concerns, Issues Assessment - Clinical work usually begins with an assessment - Interviews - Psychological tests 20-21 Focus: current controversies in assessments Focus: role of relationship skills 21-22 Formulation - Definition: psychological understanding of a client’s problems, provides a basis on which decisions about helpful interventions can be made - Structure around predisposing, precipitating, and maintaining factors - Some stick to one approach, some work in a more integrative way 22-23 Communication - Ability to communicate - What info needs to be conveyed Intervention - Trained to provide a variety of interventions → depends on formulation and depends heavily upon the psych’s decided approach - Choose one intervention or integrative - One-to-one - Group - To teams and organizations 23 Evaluation - Effective of intervention → during and after - Qualitative and quantitative 24 AFIE → do not occur in discrete stages, but they overlap and blend into each other Multi-disciplinary team (MDT) 25 Reflective practice - Reflect on your assumptions, cultural backgrounds, and life experience - MDT meetings - Supervision meetings 25-28 Senior Clinical Psychologist’s job scope - Leadership - Supervision and consultation - Teaching and training - Research and service evaluation 29 Different client groups, settings, and psychological approaches Week 2 - Lecture 1 https://padlet.com/stephanienus/ay2425-pl3257-lecture-2-irehr9wnqxelbj81 5 Part 3 - Communication - Findings from our assessment - About the client, important people in the clients life (but depends on consent because of confidentiality) - Typically, even after psych 1 transfers the information to psych 2, when psych 2 wants to transfer information to psych 1, psych 2 will need to get client’s consent - Formulation - Communicate in their “language” - Must have a strong link to the treatment plan - Treatment plan - SG guideline: therapy as the word to use (instead of treatment [global lang]) Why is it important to share our formulation and treatment plan with our clients - Having clients’ buy-in → therapy is collaborative + they need to have a say in it + informed consent - Sense of say in the process → existing power dynamics in the medical settings - Check if our formulation is correct - Trust and Rapport 6 - Communication with the client and the client’s social system - Especially for (child) clients who are dependent on the family system - Formal letters or meetings with other professional - Coordinate care and reinforce work done - Multi-disciplinary team meetings - Therapeutic letters to the client (uncommon) - Empowerment and collaboration - Built rapport - A form of intervention itself 7 Part 4 – Behavioral Intervention - Graded exposure - Reducing avoidance of feared situations - Avoidance does not allow the client to learn coping strategies - Reinforce progress (e.g., rewards) - Reinforcement will look different for different people (eg. extrinsic rewards for children) - But the goal is always to have intrinsic motivation → more impactful/lasting - Graded exposure (expose them to stimulus step by step) - Sleeping with lights on → where client is right now - Sleeping with night light - Staying in a dark room for 10 mins (increasing amount of time) - Sleeping without a night light → where client wants to be - **VS FLODDING: direct exposure 8 Cognitive Behavioural Therapy (CBT) Intervention 1. Cognition - Thought challenging - Evidence for and against - Conducting behavioral experiments (but always ensure the chances of success are high enough to not keep the client’s motivation) - Can be conducted for eg. people do not eat alone → to observe or survey 2. Body sensations - Relaxation strategies - Deep breathing - Progressive muscle relaxation 3. Behavior - Graded exposure to reduce avoidance behaviors 9 Engaging significant stakeholders - Caregivers - To aid in carrying out graded exposure, to guide the child in utilizing strategies learned, and to reinforce the child’s progression - To shorten the temporal gap → psych cannot be there at that moment to correct the behaviour, it will be effective if caregivers can reinforce correct behaviours immediately → need to train - Other professionals – school counsellors, doctors, other health professionals, social workers 10 Intervention: General Principles - Crucial that intervention plans are derived from the formulation - More structure and basis to the selected interventions - Takes into account assessment information - Choosing an intervention (tripod) - Evidence-base - Clinician’s (including supervisor) expertise - Client’s (including social system) preference - Eclectic or integrative ways of working (where appropriate) 11 Part 5. Evaluation, General Principles - Assess intervention outcomes – therapy goals and symptom reduction (evaluating the grading exposure) - Quantitative measures - Standardized measures - Personal goal ratings - Qualitative outcomes - Thorugh surveys and conversations - Review sessions in person - Check in after each session 12 The clinical golden chain - Not necessarily linear, more likely an iterative process - At each stage, additional information may become available - Informs formulation and intervention 16-20 Where do clinical psychologists work? - Healthcare settings - Community services - School / Universities - Government entities - Private practice clinics 21-25 Case study 26 Roles of a Clinical Psychologist - Direct clinical work - Clinical golden chain - Individual, group, couple, family - Onward referrals & liaison - Indirect work - Service Evaluation - Mental health research - Consultation with other professionals 27 Roles of a more senior clinical psychologist - Leadership/professional development - Strategic Planning - Implementation of evidence-based therapies - Planning of services - Team Development - Supervision and reflective team meetings - Professional Development (PD) courses - Advocacy for the team - Clinical Governance - Monitoring the clinical performance of staff - Ethics and related decision-making – investigating complaints and ethical breaches 28-29 Professionals in the service Institute of Mental Health (IMH) - Only psychiatric hospital in the country - Weekly MDT team meetings (inpatient wards) - Psychiatrists, Medical Social Workers, Occupational Therapist, Nurses, Case Managers, Pharmacist, trainees, Psychologist - Attached to a psychology department - Clinical psychologist as Head of Department - Clinical supervision - Peer supervision Additional Examples of MDT Teams - Tan Tock Seng Hospital Rehabilitation Team - Weekly MDT team meetings - Medical doctors, psychiatrists, medical social workers, sppeech and language therapist, occupational therapist, physiotherapist, nurses, case managers, pharmacist, psychologist, trainees 30-34 Frameworks of Practice Scientist-Practitioner - Applying knowledge obtained from scientific study of psychology to aid in the relief of psychological difficulties/distress Empirically Supported Treatment - Evidences that we have that an intervention works - National Institute for Health and Care Excellence (NICE) guidelines (subset) - Schizophrenia, Eating Disorder, Self-Harm, Depression, Anxiety (GAD and Panic), PTSD, Childhood Depression, OCD, Bipolar Disorder, Dementia, Ante/Postnatal Mental Health, Alcohol dependence, Autism Spectrum Disorder, etc. - Gold standard: Randomized controlled trials - Examines how well interventions work in carefully controlled conditions - Clients with similar difficulties are recruited (e.g., individuals with a panic disorder diagnosis and only this diagnosis – no comorbidity) - Assessments made with well-established measures - Clear protocols (interventions are applied consistently) → + to be clear on what each session covers - Clear comparison conditions (e.g., intervention vs control or another type of intervention) - Limitations of RCTs - Studies that get published tend to have significant results, non-significant results might not get published - May overlook individual differences - NICE guidelines birthed from a certain place and culture which may not be applicable to all cultures - The culture of the participants recruited has to be taken into account - Amount of research that has been conducted on CBT > Research conducted on other therapy models 35 Evidence-Based Practice - Approach to clinical decision making - A difficult balance? - Depends on own expertise and socialization of the client (Singaporean clients tend to defer to the clinician) - Evaluation of outcomes is important - Individual goals - In some settings, there are set measures to evaluate but not all → psych needs to evaluate if these measures can accurately measure sensitively → psych can add their own measure - The trifactor - Research evidence - Clinical expertise - If psych is not trained in something: - Can get client’s buy-in for another method - Psych be closely supervised - Refer - Get trained - Client preference 36 Reflective-practitioner - Reflective practice is both a reflection in action and on action - In-vivo (in the moment) and post-hoc (after session) - In-vivo: notice → post-hoc: reflect → supervision - Selves are part of the work as therapy is a relationship - Reflection is done in supervision - Psych’s own implicit ideas/beliefs might affect how they execute their practice → eg. psych comprehension of religion but religion might have a great effect on the client’s experience → would not be an effective therapy - Learning from mistakes but also learning our (often implicit) beliefs and values 37-38 Reflective practice: Step 1 – Deconstruction - Thinking about the work - “Did the technique you used achieve something that would not have been possible using other conversations?” - Thinking about the interviewee - “What thoughts and feelings do you think the interviewee had in sessions?” - “How could these thoughts and feelings have influenced your interviewee’s responses in session?” - Thinking about the interviewer – Self-reflexivity - “What thoughts and feelings did you have when you were conducting the interview? What was happening during the interview that made you think and feel that way? How might these thoughts and feelings influence your responses during the interview?” - “What personal biases and assumptions from your past experiences might explain the thoughts and feelings you had?” - “What contextual (social/cultural) factors could explain the thoughts and feelings you had?” - Psych might project their need for advice/problem-solving → lead into solving issues for the client or moving into solving too early - What we think or feel in vivo might influence how we execute the practice → might miss certain important moments of silence because psych is too concerned thinking about what to ask or say next 39 Reflective practice: Step 2 – Reconstruction - Thinking about past action - “Now that you have relooked at the interview more closely, would you have done things any different?” - “What cost or benefit would those alternatives have?” - Thinking about future practice - “What have you learnt that could help you on your own journey as a professional psychologist?” - “What could you do to develop these skills? How has this experience affirmed or changed your perspective on clinical psychology practice?” Week 2 - Reading: Chapter 2: The Art and Science of Psychological Practice 18 The Scientist-practitioner - Applying rigour and knowledge obtained from science to the practical problems faced by practitioners in everyday life - Apply research evidence from: - Randomised Controlled Trials (RCT) - Effectiveness trails - Case series - Experimental research - Empirically supported treatments (ESTs) 19 NICE-recommend psychological therapies for different mental health diagnoses for adults 19-20 RCTs - Considered ‘gold standard’ in outcome research - Key elements Meta-analysis 20 Limitations in interpreting evidence base - ESTs (based largely on RCTs) - 3 others Importance of evidence-based practice in response^ 21 Focus 2.3: Choice of therapy 21 The Reflective Practitioner - Skilled psychology practice consists of far more than just simply following prescribed techniques - Key elements - Reflection in action - Reflection on action - Critics of this 22 The Critical Practitioner - “Critical lens” to their practice in an attempt to ensure their practice does not unintentionally contribute to continuing social inequalities and injustice - To question our own practice 23-24 3 frameworks in clinical practice - Rigour of the scientist-practitioner - Skills of the reflective practitioner - Perspective of the critical practitioner Decisions must be negotiated with the client 25-26 Core models of Psychological therapy Behavior Therapy - Main focus: classical conditioning + operant conditioning - Behaviour view of psychological distress - Case study: Anna 27 Cognitive-behavioral therapy (CBT) - Main focus - Case study: Anna 28 Psychodynamic therapy - Most are short-term - Case study: Anna 29 Systemic therapy - Case study: Anna 30 Reflecting on therapy - Integrative approach Week 2 - Reading: Chapter 3 - Working in Teams 34 Overview 35-37 Introduction to professional roles within mental health - Service managers - Psychiatrists - Clinical psychologists, counseling psychologists, and psychological therapist - Community mental health nurses (CMHNs) - Occupational therapists (OTs) - Social workers - Nursing assistants, support workers, and peer support workers - Administrative Staff 38-41 Different perspectives brought to the understanding of human distress - Diagnosis - Formulation - The biopsychosocio model - Recovery-orientated practice 42-44 A clinical psychologist’s role in multi-disciplinary teams - Team formulation - Clinical leadership - Staff support 44-48 Sarah’s case study Week 3 - Tutorial 1: Readings and Class Videos Rapport Building - Helpful Rapport Building - Unhelpful Non-verbal - Helpful (From reading) - Internal and physical attending - Coming in with many thoughts but what is important is being physically present and putting everything else at the door - Minimal encouragers - SOLER - Squared → Facing the client - Open → openness, eg. to not cross arms or legs - Lean → leaning forward to show interest - Eye contact → look at them - Relax → Be aware of your self-comforting actions (eg. eyebrows may tense up when they are stressed) - Tone - Playing around with how you sound - You might sound different from what you intend the listener to know - Eg. Lowering voice, slowing it down - Silence - Where appropriate, to give the client time to think and process R1 Verbal - Helpful Verbal - Unhelpful Admin For the presentation: formulation → CBT (simple form, no need for 4Ps) - Week 9 and 11 Tutorial Active Listening - How is different from a normal conversation: In normal convos, we might give solutions, advice, personal stories - Open-end questions - Eg. tell me about your day. - What is the difference between paraphrasing and summarising - Paraphrasing: restating what the client has said in a non-judgemental way - You want to pick out the key themes/issues and keep it short and succinct → to crystalize the issue - Not meant to be long and detailed → summarising - Use a summary when the client has said a lot *Depends on the relationship the psychologist has with the client - Psych can exaggerate or downplay - The word choice can evoke different emotions - Eg. choosing to talk about the feeling of frustration or the fear of rejection → client might end up talking about the present or the past respectively Qn: Extrapolating vs Paraphrasing - Extrapolating → reflecting their feelings - To deepen it - It’s okay to extrapolate so long as it is non-judgment → reasonable feeling - Feeling we do not want to talk about guilt, shame, jealousy → to point that out needs rapport building The transition from rapport-building to deeper topics - Rapport building and deeper topics could both have usable info - Rapport building is especially important for kids, teenagers, mandated clients - What could help: being present and listening, being interested, instead of overthinking what to ask later - The art of it: weaving in personal experiences (but different psychologists will have different approaches) Week 3: Chapter 5: Beginning Conversational Skills: Joining and Maintaining an Interview 143-145 Joining skills - Make and maintain a connection - Internal attending - Physical attending - Verbal attending 145-149 - Greeting the client - Framing purpose of therapy - Therapeutic distance (unconditional positive regard) - Door openers → non-judgemental way of opening a convo 150-156 Basic Conversational Skills - Minimal encouragers - Verbal and non-verbal - Nonverbal communication - The content and the PROCESS - Body position - SOLAR - SURETY - Proxemics - Eye contact - Voice tone (paralanguage) - Attitude - Note taking 156-160 - Listening - Listening barriers → environmental, psychological, or cultural - Responding - Silence - Productive silences - Neutral silences - Obstructive silences - Using the client’s language (eg. visual manner) - Using obscenities 161 - Use of humour - Exaggeration - Therapist self-depreciation - Absurdities - Confrontations (empathetically) - Immediacy - Feedback Week 3: Chapter 6 – Basic Reflecting Skills - Exploring Client Content 167 Issue Cycle 167-176 Exploring content - Client stories - Content → Feelings → Meanings - What is content - PARAPHRASE - Issue cycle: Door opener → Minimal Encouragers → Paraphrase - Building paraphrases - General and specific - Non-judgmental - Connecting paraphrases with basic conversational skills 177-179 - Use of metaphors - Client-genreated and therapist-generated - Usually used as paraphrases Week 3 - Lecture 3: Working with Children and Families 1 CBT → thought Schema therapy → on childhood experiences 2 Lecture Objectives - By the end of the lecture, you should be able to: 1. Articulate the key principles of Systemic Theory 2. Differentiate functions of questions posed to a client and his/her system during a session (assume therapist is working from a systemic perspective) 3. Identify factors to be considered when working from the Systemic Theory perspective 4. Apply aspects of behaviour-focused parenting interventions 5. Apply aspects of attachment-focused parenting interventions 3-8 Theories in Clinical Practice Systemic Practice - Psychological difficulties are related to the relationships among members of the system - Systems within systems (e.g., sibling sub-system, spousal sub-system, parent-child sub-system – parent A with child A; parent B with child A) - Circular (rather than linear) assumptions about associations - Circular: A influences B, B influences A - Linear: A → B - Circular questioning → To learn about connections between individuals in the system - Difficult to identify IVs and DVs because they all influence each other 10-14 Circular questioning - Explore patterns of interaction in relationships - Generate contextual understanding - Types of circular questions: 1. Behavioural-effect questions - Behaviour + effects behaviours have on the client - Function: To obtain descriptions of behaviors and emotional/thought/behavioural responses to the behaviors - E.g., What do you do when she raises his voice at you? (I keep quiet). And when you keep quiet, what does she do? (She yells even louder and ask why I’m not responding). And when she yells louder, what do you do? (I get scared, start crying, and walk away). 2. Intrapersonal perception questions: - Similar to theory of mind - Function: Focus on an individual’s understanding of another person’s experiences - E.g., What do you think goes through Clare’s mind when you raise your voice? What do you think goes through your parent’s mind when you don’t inform them about your whereabouts? 3. Triadic questions: - Function: Focus on the interactional patterns between two or more people. Focus on thoughts, feelings, and behaviors involved in an interaction - E.g., What does dad do when Clare and mom are in an argument? 15 Further factors for consideration: - Circumstances of the family that may disrupt stability in the system - SES, migration, parental separation, family life cycle (a few stage – marriage (2pax) → child (3pax) → 2 children (4pax) - Understanding aspects of identity and how it shapes experiences - Social GRAAACCEESS (“Gender, Race, Age, Ability, Appearance, Class, Culture, Education, Employment, Sexual orientation, Spirituality”) - E.g., Clare father’s views that men should be breadwinners of the family, while mothers care for the house/children. [culture] → his action of spending time at work is in line with his views. - One’s own identity can affect how they view the roles of others/perceptions of others → might not always be clinically relevant - Therapists (and their beliefs and biases) are now part of the system - E.g., if therapist asked, “Do you view that by dad working, and bringing income, is his way of caring for the family?” - Reflective practice is important! - If dad did not say that he feels a certain way/implied it, psych could be bringing up their own belief instead - If psych brings it up, it could broaden mom’s viewpoints by adopting theory of mind - BUT mom might feel invalidated or dismissive - There are other ways to do so (eg. asking dad to share) - Adopting this TOM depends on mom’s head of understanding at the moment 16-18 Systemic formulations - Has a circular assumption → The formulation will look like a network - Each can have different beliefs and expectations influenced by their own life experience → affects the system → see how we can balance Conceptualizing the problem - Problem-deconstruction - What the client is in therapy for? Why now? Who sees it as a problem? Do other members in the system perceive the “problem” differently? - Parents would like help in “managing” Clare’s behaviors. Mother sees Clare as being defiant, father thinks Clare’s behaviors are typical of teenagers. Clare does not view her behaviors as problematic. - Contextual factors - Family structure, how the problem has started and evolved over time - Parents married – described spousal relationship increasingly tense. Frequent intense arguments – often witnessed by Clare. - Father was retrenched approximately 8 months ago and found a new job approximately 2 months ago → couldn’t fulfil his role as a breadwinner? - Clare’s behaviors started approximately 4 months ago. - Though there is an delay/retention of behaviour → we need time for the system to stablise - Claire’s behaviour is a new factor introduced into the system and it does not just disappear when dad gets a job - Beliefs and explanations - What does the problem mean to the different individuals of the system?, beliefs and expectations about the problem, of self, and of others. - Mother perceived Clare’s behavior as a reflection of failed parenting on her end and due to the influence of “bad company”. - Mother’s parents have often spoken about how a child develops depends on the way parents’ guide the child. - Mother views that father should also play a role in parenting Clare. - Father views that Clare’s behaviors a common among adolescents and she will “outgrow” them. - Father believes that men should be breadwinners of the family, while mothers care for the house/children. - Clare enjoys being out with friends, describe staying at home as stressful. - Patterns perpetuating the problem, emotions, and attachments - Boundaries, subsystems, escalating patterns of interactions, repetitive patterns of interactions - Subsystems: spousal subsystem in conflict, mother-child subsystem in conflict - Spillover of emotions and unmet needs from the spousal subsystem into the mother-child subsystem. 19-25 Part 1. Parent coaching: Managing behavior - The BIG idea in such programmes are simple… “Increase good behaviour”… it will see-saw with bad behaviours Increasing desired behaviours - Learning to use the skills of: 1. Attending without agenda (10-15 minutes a day) → Gradual - To not have a “teaching moment” - All children crave the attention of their caregivers – use it well! - Joint play without instructions or demands - Follow the child’s lead - Running commentary on the activity → describing their observation → instead of “why don’t you do it the other way?” - Purpose: improves child’s attention and parent’s sensitivity to the child 2. Using rewards - What the child thinks is a reward and not what the parent thinks → can be non-material like praises/attention; something that the child does not have free access to; sustainable for parents - Main principle: - Clear instructions - Immediately following desired behaviour - Types: Attention, physical contact, verbal (be specific), material - Reward charts: Agree on a behavior and how it is evidenced - Define behavior as how you would like the child to behave, rather than telling the child what not to do - Eg. “no running” → if child starts jumping, technically we should reward it - Difficult for parents to figure what they want to see, it is easy to define what they don’t want to see - Consider where the child is right now then adopt gradual exposure 3. Ignoring bad behaviour - Make sure child will be safe - Make sure it is complete - No verbal or non-verbal communication - No physical contact - Return attention only when appropriate behaviour is demonstrated - Expect the behaviour to get worse before it gets better - If this bad behaviour has worked before, the child might enhance the behaviour until proven that this behaviour does not work - Is the behaviour serving a function? 26-28,30 Reflective parenting: Attachment-focused - Model assumes that - Children’s behaviours are not just conditioned responses (needing behavioural management) but their way of communicating thoughts and feelings - Give parents the space to reflect on their interaction with their children to deepen understanding of the problem - From time to time taking a step back rather than get caught up in the problem - Done with 2 reflective steps - What parents bring to the interaction (Parenting Map) - A way of reflecting about the self and how the parent parents the child - The meaning of the child’s behaviour (Parenting APP) - Encourages parents to be attentive and curious about their children - Aids parents think about what might be going on inside the child’s mind - Three main elements: attention, perspective taking, providing empathy 29 The Parent Map - what parents bring to the relationship - Identifying your sources of stress - Personal history - Is there anything in your past that may explain why the current situation is so stressful? - Current life situation - Are there relationships or other responsibilities (e.g., work and finances) that add to your current stress levels? - Current level of emotion - Are you feeling overwhelmed or underwhelmed? Week 3 - Reading: Chapter 4 - Working with children and young people 53-54 Rachel’s story + introduction 55 Normal childhood development and its pitfall - Many factors 55-57 What psychological difficulties can occur for children and young people - Erikson (1950/1959) - Green (2005) 57 Diagnosis - Can be unhelpful 58 Aetiology - Causes of emotional and behavioural difficulties - biopsychosocial 59-60 Psychological help for children and young people - Settings - Consent 60-63 The use of theory and evidence in psychological practice - Conduct disorder - Anxiety - ADHD - Depression - Eating disorders 63-66 Communication and creative in working with children Case study - formulation, etc 67-68 Critical issues - Multi-agency working - Person-centred recovery → broader sense instead of loss of symptoms which can never truly happen Week 4 - Lecture 4: School observations Lecture Objectives 1. Explain how school observations can be a helpful part of initial clinical assessments. 2. Articulate information to obtain during school observations. 3. Articulate information to obtain during teacher interviews. 4. Describe the different formal psychological tests used to assess learning. 5. Plan the use of questionnaire measures in clinical practice. Discussion: what to look out for in school observations - Observe symptoms of the possible disorder (+ look out for other disorders) - Observe structured and unstructured environments - Structured: class, group work, etc - Unstructured: recess, between classes - Take note of the child’s fav subj class, least fav, P.E. 4 Setting the Stage - Preparing the school for your arrival - Check if the school has had observation done before - If not, ensure they understand why you are coming - Clarify your cover story - Ensure the teacher does not announce who you are there for - “Here to observe the class” → broadly, to not alarm the client *First session/assessment - Should not see the child first (so the child does not know that they are being observed → demand characteristics) - See parents to get a sense of the child’s issues and background 5 Interview Schedule with Teacher - Language/Academic Performance - Strengths and weaknesses? - Progressions and regressions? - Interventions offered (extra support, small groups)? - Age-appropriate learning? - Overly formal speech? - Social Skills - Friendships and their progression? - Bully or get bullied? - Prosocial behaviors? - Emotions - Low moods or anxiety? - Other concerns about the child? 6 Formal Psychological Tests - Assessments of Intellectual Functioning, and Assessments in Context - Standardized → relative to age group + standard and strict administration of test 7 Defining Learning (Intellectual) Disabilities – DSM5 - Two SD or more below population mean (IQ tests: mean of 100, SD of 15, IQ scores < 70) - Concurrent problems with adaptive functioning (adaptive func is different from intellectual func → 2 diff components) - i.e., the person’s effectiveness in meeting the standards expected for his or her age by his or her cultural group - In one or more of the following areas: communication, social participation, and independent living - And across multiple environments, such as home, school, work, and recreation. - Onset during the developmental period 8-9 Assessment of Intellectual Functioning 1. Wechsler Adult Intelligence Scale (WAIS-IV) - For young persons and adults aged 16:0 to 90:11 2. Wechsler Intelligence Scale for Children (WISC-V) - For children aged 6:0 to 16:11 3. Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV) - For children aged 2:6 to 7:7 The ages overlap - Chose the item that the child would be more motivated - Consider penmanship → can the child write and understand - Ie. if we think the child has a lower IQ, the adult version is harder, the sense of discouragement kicks in faster → can start from the “easier questions” 10 Domains Assessed (WISC-V) - Verbal Comprehension Index (VCI) - The ability to listen to a question, draw upon learned information, reason, and express their answers verbally - Not suitable for children that are non-verbal - Visual Spatial Index (VSI) - The ability to evaluate visual information and visual-spatial relationships to construct geometric designs - Fluid Reasoning Index (FRI) - The ability to identify patterns in visual objects and to apply these rules - Working Memory Index (WMI) - The ability to register, retain, and manipulate visual and auditory information that is kept in mind - “1…2…” → pacing matters (1s per number) then repeat - Processing Speed Index (PSI) - Assesses children's abilities to scan and discriminate between visual information quickly - Motor speed + visual screening 11 Features of Psychological Tests - Standardised administration - All in the instructions). - Accommodations may be necessary but must be noted (e.g., conducted in client’s home). - Results are norm-referenced - Representative sample that is matched by age - Cutoff scores. - Validated in either the US or the UK. 12 Sample cognitive profile 13 Consideration of Results in Context - Some factors affecting results: - Fatigue → avoid after school - Motivation → strategies for children: breaks, stickers as rewards. Upper primary onwards are typical okay - Distraction - Language - Some tests may not have other languages - To what extent does lang affect the child’s results → clinical judgement - To counter these factors: - Starting points (5yo starts at item 1; 16yo starts at item 10) - Rules: eg. reversal rule → if cannot do item 10, go back to item 9 14-16 Cognitive tests in context - Vineland Adaptive Behavior Scales, Third Edition (Vineland-3) - Forms: - Interview form - Parent/caregiver form - Teacher form 17 Parent/Care-giver questionnaire example 18 Sample adaptive functioning – CI interval and Clinical judgement 19 Take Home Points - Assessment scores must always be interpreted in context. - Additional considerations: - Is a diagnosis helpful? - Exploring the meaning of diagnosis - Exploring the consequences of diagnosis on education opportunities. 20-23 Why use questionnaires in assessments? - Benefits for assessment - Can provide multiple perspectives and in different settings - Highlights differences in opinion - Quick clinical screening of symptoms (general profile) - Indicate if a more thorough assessment is needed - Benefits for MDT working - Good tool for the communication of your assessment findings - Collaborative working with others in the system - Potential costs? - Can obscure as much as illuminate → Blind to topics that are not surveyed - “Death by questionnaire” (too many questionnaires may hurt rapport) Considerations - Informant - Self, family members, teachers - Degree of insight 24 Examples – CBCL/TRF/YSR - Achenbach System of Empirically Based Assessment (ASEBA) - Pre-school forms (for Ages 1.5 to 5) - Child Behavior Checklist (CBCL) - Caregiver-Teacher Report Form (C-TRF) - https://aseba.org/preschool/ - School age forms: - Child Behavior Checklist (CBCL): Ages 6 to 18 - Teacher Report Form (TRF): Ages 6 to 19 - Youth Self Report (YSR): Ages 11 to 18 - https://aseba.org/school-age/ *choose based on: age + how to fill the form 25 - Syndrome scales - Anxious/Depressed - Withdrawn/Depressed - Somatic Complaints - Social Problems - Thought Problems - Attention Problems - Rule Breaking Behavior - Aggressive Behavior - - Hint to us the problem areas 26-30 Examples – RCADS - Revised Children's Anxiety and Depression Scale (RCADS) → very specific (CBCL/TRF are broader) - RCADS – Self-reported: Ages 8 to 18 years - RCADS – Parent version - Subscales: - Separation anxiety disorder, social phobia, generalized anxiety disorder, panic disorder, obsessive compulsive disorder, and low mood (major depressive disorder) - Total Anxiety Scale (sum of the 5 anxiety subscales) - Total Internalizing Scale (sum of all 6 subscales) - Open to clinical judgment → e.g. if psych thinks a 7yo can do this test, they can also administer this one - Profile: - 31 Questionnaires for treatment evaluation How do we know the treatment is working? - Can repeat questionnaires but not standardised test (ST typically yield the same results) Have flexibility → eg. for ADHD, but open to comorbidity Questionnaires can be used for clinical and research settings - Almost all clinc qns can be used for research but not the other way around 32 Types of Questionnaires - Symptom-based: - PHQ-9, GAD-7 - Broad functioning: - Outcome rating scale - Therapeutic alliance: - Session rating scale 33 Purpose of questionnaires - Evaluation - Progress of therapy - Enhance motivation and engagement - Informs end-of-therapy discussions 34-35 Depression: Patient Health Questionnaire (PHQ-9) Anxiety: GAD-7 37 Assessing progress in therapy - Outcome rating scale (ORS) 38-40 Assessing Therapeutic Alliance - Rapport - Similar procedures to ORS - End of the session (5-10mins) → in case we run out of time - Session Rating Scale (SRS) - - Child Session Rating Scale (CSRS) - 41 42-43 Setting the stage for School Observations - Preparing the school for your arrival - Check that the school has had observation done before - If not check that they understand why you are coming - Clarify your cover story - Make sure that the teacher does not announce who you are there for - “Here to observe the class” 44 Observations in different contexts 45-46 Specific behaviours to look out for - ASD - ADHD 47 Interview schedule with the teacher Week 4 - Reading: Chapter 5 - Working with Families 73-74 D’s story + Introduction 75-76 Systemic practice - Mobilise the strengths of their relationships so as to make disturbing symptoms unnecessary or less problematic - Features 77 Relationships and the brain 77-78 Help for families: family needs and service responses - Family therapy and types 79 Use of theory and evidence in practice - Effectiveness and different types of systemic therapy - Effectiveness of FAMILY THERAPY in children’s and young people’s services 80-83 Case study 83 Critical issues - Culturally sensitive practice - Expert or reflective-practitioner 84 Conclusion Week 5 - Lecture 5: Working with Individuals with Anxiety 2 Lecture Objectives By the end of today you should be able to: 1. Articulate theories of anxiety 2. Discuss the elements of a CBT intervention for someone who has difficulties with anxiety - Articulate the rationale and apply the following strategies: Psychoeducation + Behavioral experiments 3-4 Behavioural Theories of Anxiety – FIRST Wave - Classical conditioning - Example: Developing a fear of public spaces after experiencing symptoms of a panic attack there - Operant conditioning - Avoidant behaviours: Learning that staying away keeps you safe → negatively reinforcing - Safety behaviours: Learning maladaptive ways of coping - Social anxiety: word-for-word script → doesn’t fumble → reinforced - Social learning theory - Example: My hatred for cockroaches is socially mediated? → when nothing actually happened between me and cockroaches Suggest that recovery can be achieved by the same learning principles → instead of avoid, approach 5 Cognitive Theories of Anxiety – SECOND Wave - The operative word being “perceived” - Coloured by past experiences and learning - Thought processes → CBT → change client’s perceived thoughts and consider alternative perspectives - Suggests that recovery can be achieved: - Beginning with insight - Followed by the testing of alternative perceptions 6 Anxiety-Specific Cognitive Vulnerabilities - Panic Disorder - Concern about the consequences of an attack based on a misinterpretation of physical symptoms (Anxiety sensitivity) - Example: “I feel dizzy, I am going to have a panic attack!” - Focus on physiological sensations - Social Phobia - Concern about judgments from others and making a fool of yourself (Fear of Negative Evaluation) - Example: “Everyone is looking at me!” *CBT → focus on thought process → can have specific and unique domains + listen to the way the client talks (what is their focus) 7 - Generalized Anxiety Disorder - Concerns about the uncertain future and your ability to cope (Intolerance of Uncertainty) - Example: “What if…” - Meta-beliefs about worrying being good or bad - “Worrying helps me do a good job” - (worry serves as a function → challenge it → what other reasons you have other than worry) - “Worrying is going to lead to depression!” - OCD - Concerns about the consequences of obsessions - Example: “My house will burn down if I don’t check the cooker” - Beliefs about the efficacy of the ritual (taking personal responsibility) - “If I say a prayer these number of times I will be safe” 8-9 Therapy Targets – Thoughts and Behaviours (Responses) - Thoughts: - Disorder-specific cognitive vulnerabilities - Behaviours: - Avoidance - Safety behaviours - Selective attention - The info they give can be skewed to align with their condition → eg. anxiety will lead to a focus on certainties and uncertainties - Hence, in therapy, explore alternatives and aim for a broader perspective 10 Therapy Targets – Behaviours - Panic Disorder - Avoidance: Alcohol, self-medicating - Attention and safety behaviours: Monitoring pulse, listening to the heart - Social Phobia - Avoidance: Missing social events - Attention and safety behaviours: Keeping head down, walking quickly, avoiding eye contact - Psych can use a board → both will look at the board - GAD - Avoidance: Ignoring texts/emails from a boss - Attention and Safety behaviours: Reassurance seeking, excessive research, over-preparing 11 Therapy Targets – Responses - OCD - Avoidant: Thought suppression, constantly keeping the mind occupied - Attention and Safety behaviours: Checking, washing, rituals 14 Formulation (CBT) 15 Formulation 2 16-18 Evidence-based practice: NICE guidelines 19-21 Psychoeducation about anxiety - Principles behind this intervention: - Greater understanding of the function and expression of anxiety in the body → Normalizes the experience (less shaming) - Greater understanding of these NATURAL processes so the client does not jump to the wrong conclusions - Eg. you cannot control sweating 22-25 Behavioural experiment: Self-focus attention - Task: Speak to a stranger (receptionist of the clinic) - Experiment 1 – Have a 5 minute conversation - Self-focused attention - To focus on how feelings in the body and what is going through the mind when having the conversation - Experiment 2 – Have a 5 minute conversation - Other-focused attention - To focus on what the other person was communicating verbally and nonverbally. - Check how he found both exercises and help him reflect on the experience *Remember to set client up for success - Principle behind this intervention - Help clients to see the association between self focus and heightened social anxiety - Help client see how a self focus could have maintained his problems all these years - Skill training in directing focus outwards 26-29 Cognitive intervention: Video feedback - Daniel had the self perception that he was a “weakling” and a “fool” - Get Daniel to define what that means - ◦ “Blushing (RED) around the face and neck” - ◦ “Sweaty look around the face, neck and hands” - ◦ “Dress not fitting with people” - ◦ “Not meeting gaze (not more than a split second)” - ◦ “A lot of silences” - ◦ “Saying things he is not interested in” - ◦ “Fidgets to the point of distraction” - ◦ “Sudden changes in topic” - Daniel then rated his performance speaking to the receptionist using all these dimensions - One week later, Daniel was shown a video of that conversation he had and then rate ‘the man’ in the video on all these dimensions again - ◦ “Blushing (RED) around the face and neck” - ◦ “Sweaty look around the face, neck and hands” - ◦ “Dress not fitting with people” - ◦ “Not meeting gaze (not more than a split second)” - ◦ “A lot of silences” - ◦ “Saying things he is not interested in” - ◦ “Fidgets to the point of distraction” - ◦ “Sudden changes in topic” Results: - Principle behind this intervention - Beliefs are not unitary constructs and can be broken down and challenged - Challenging the client’s view of himself using the very criteria he came up with and the ‘cold hard evidence’ of a video of himself (cognitive result) 30-33 Behavioural experiment: Exposure outside the clinic - Typically we try in the clinic first → controlled setting - “Others are judging me!” or are they? - Experiment with dropping safety behaviours on the MRT - No looking at phone; making eye contact - Learn how to know if “people are judging” to ensure that the results are accurate - “If I show weakness others will take advantage!” - Experiment 1: Speaking loudly (normative loud) on my phone at the bus stop talking about my anxieties about work - Experiment 2: Walking (normative walk) around the community with sweat patches under the arms *Set client up for success (eg. when talking loudly, make sure it normal loud and not obnoxious because people will definitely judge you) - Principle behind this intervention - The learning in clinic needs to be generalized to other contexts! - Learning that he has the ability to cope with distress without safety behaviours - Learning that his self conscious thoughts are not realistic in the community - Learning through experience is more powerful *Reason to do experiments → “You are psychologist, of course you will understand, others won’t” 34 35 - Use therapy skills for negative automatic beliefs → then gather evidence to target the core beliefs - Differentiate what is a thought and a feeling 36 Week 5 - Reading: Chapter 7 - Working with Anxiety Disorders 108 Millie’s story + Introduction 109-110 Types of psychological difficulties that may occur in anxiety disorders - Cognitions - Affect - Physiology - Behaviours - DIAGNOSIS 111 Epidemiology - Co-morbidity and anxiety disorders Aetiology 112-113 Factors - Biological - Environmental - Psychological - Behavioural theory: classical, operant, social learning - Cognitive theory 113-114 Theory and evidence for psychological intervention - Behaviourally-based exposure therapy - CBT - Cognitive distortions - Eye movement desensitisation and reprocessing (EMDR) 114- 120 Case study - Formulation - GAD maintenance model 120 Team working/indirect work 121 Critical issues - CBT for specific anxiety disorders - Trans-diagnostic treatments 122 Treatment models for main anxiety disorders - Specific phobias - Social phobias - Panic disorders - OCD - GAD - PTSD - Health anxiety (illness anxiety disorder) 124 Conclusion Week 5 - Tutorial 2: Readings and Class Videos Normalisation Competency - Helpful

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