How psychological treatments developed
Classification of psychological treatments
Common factors in psychological treatment
Counselling and crisis intervention
Individual dynamic psychotherapies
Treatment in groups
Psychotherapy with couples and families
Psychotherapy for children
Psychotherapy for older people
Treatments of mainly historical and cultural interest
Ethical problems in psychological treatment
This chapter is concerned with various kinds of counselling, psychotherapy, behavioural and cognitive therapies, and some related techniques. The UK is almost unique in having a separate faculty and specialist training in psychotherapy for psychiatrists. In most settings, psychotherapy is considered a core aspect of a psychiatrist’s role, indeed their professional identity. It is no longer routine for trainee psychiatrists to be trained fully in one or other form of psychotherapy, but rather they gain an overview. It will be obvious, however, that much of what follows below is inevitably woven into the daily practice of psychiatry. Expectations of this competence are likely to vary in the near future, but are unlikely to disappear.
The subject is large, and the chapter will be easier to follow if the reader’s attention is drawn at this stage to certain aspects of the organization of the chapter.
• Psychological treatment is not given in isolation, and the account in this chapter should be read in conjunction with the general advice about treatment in the chapters on physical treatment and on services.
• This chapter contains advice on the general value of various treatments. Advice about the value of these treatments for specific disorders is given in the chapters concerned with the relevant disorders.
• Psychological treatments are often combined with medication. Appropriate ways of doing this are considered in the chapters concerned with the relevant disorders.
• Because many different techniques of treatment are considered here, none can be described in detail, and suggestions for further reading are given in several places in the chapter.
• Although outline descriptions of technique are given in several places, supervised experience is essential before any of these treatments can be used with patients.
Terminology. The word psychotherapy is used in two ways. In the first usage, psychotherapy denotes all forms of psychological treatment, including counselling and cognitive–behaviour therapy treatments. In a more traditional sense, psychotherapy indicates an established psychotherapy (usually broadly psychodynamic) that requires a specific and elaborate training, often involving personal experience of the therapy, and excludes counselling and cognitive–behaviour therapy. We have generally used the term psychological treatment to denote the broad sense. When we use the word psychotherapy, we usually qualify it to indicate a more precise meaning—for example, brief dynamic psychotherapy.
How psychological treatments developed
The use of psychological healing is as old as the practice of medicine—parallels have been drawn with the ceremonial healing in temples in ancient Greece. However, in the history of psychiatry, psychological treatment then starts at the end of the eighteenth century with developments in hypnosis. Anton Mesmer (1734–1815), a Viennese physician, came to prominence in 1775 when he challenged the then current practice of ‘casting out devils.’ He believed that the functions of the body could be influenced by magnetism (both from actual magnets but also from the therapist’s ‘animal magnetism’) (Burns, 2006). A Manchester doctor, James Braid, considered ‘mesmerism’ was related to sleep, and suggested the term ‘hypnosis’ (Braid, 1843).
Treatment with hypnosis became popular in France, where a disagreement arose about whether it could work only with ‘hysterics.’ Jean Martin Charcot (1825–1893), an influential neurologist at the Salpêtrière hospital in Paris, acknowledged that hypnosis worked through suggestion but considered it a pathological state occurring only in hysteria.
In the late nineteenth century, most neuroses were treated by neurologists, and when Freud began practice as a neurologist he saw many neurotic patients. He visited Charcot in France to study hypnosis, and back in Vienna he tried it with some patients. At first he was impressed by its results, but soon identified their transience. He used hypnosis not to change symptoms directly, but to release the emotion associated with the repressed ideas that he believed to be their cause. This ‘cathartic’ approach was more successful. However, the major step forward was when Freud incorporated the earlier observation that patients could recall forgotten events without hypnosis. Freud initially asked his patients to shut their eyes while he placed his hands on their forehead (Breuer and Freud, 1893–95). Subsequently he discovered that recall was as effective when the patient simply lay on a couch while the therapist kept out of sight. From this the method of free association developed. Freud began to encourage free associations and to comment on their significance, and, in time, he learned that it was necessary to attend to and control the intensity of the relationship with his patients. These discoveries formed the basic technique of psychoanalysis and subsequently of the larger group of dynamic psychotherapies. The interested reader is recommended to read one of the accounts written by Freud of the development of his techniques (Freud, 1895a, 1923).
Gradually, psychoanalytical and related techniques became more widely used than hypnosis or persuasion. Freud published vivid accounts of new treatment and elaborated his theories in increasingly complex ways, forming a ‘school’ of psychoanalysis. Some of these later disagreed with Freud and formed their own ‘schools’ of dynamic psychotherapy. These developments will be described briefly. More detailed descriptions are widely available, and for a brief overview see Burns (2006).
In the same period that Freud was developing his ideas, Pierre Janet (1859–1947) investigated the use of hypnosis for hysteria. Janet concluded that neuroses were caused by a loss of the normal integration of mental activities, a process he called dissociation. Janet used suggestion to reduce symptoms, but failed to establish an influential following. He remained bitter that Freud had appropriated his ideas. Some of Janet’s ideas about disassociation have resurfaced with interest in multiple personality disorder and dissociative states.
Early departures from Freud’s original group
Alfred Adler left Freud’s group in 1910. He rejected the libido theory (see p. 88) and stressed social factors in personal development. He considered the striving for power to be central, and coined the term ‘inferiority complex.’ His therapeutic technique of ‘individual analysis’ focused on current problems and solutions. He influenced the dynamic–cultural school of American analysts (see below). For more information about Adler’s contributions, see Henri Ellenberger (1970). Carl Jung emphasized the inner world of fantasy, and the interpretation of unconscious material, deduced from dreams, paintings, and other artistic productions. Jung believed that part of the content of the unconscious mind was common to all people (the ‘collective unconscious’) and was expressed in universal images which he called archetypes. In Jungian therapy, the relationship between therapist and patient is more equal, and the therapist is more active and reveals more about himself (Storr, 2000).
The neo-Freudian school of analysis developed in the USA in the 1930s. Its members accepted that the origins of character and of neurosis are in childhood. Like the Tavistock analysts during the First World War, such as WHR Rivers and Charles Myers, they rejected Freud’s centrality of early infantile sexuality. Family and social factors were considered more important. Three important figures in this school were Karen Horney and Erich Fromm, both refugees from Nazi Germany who settled in the USA in the 1930s, and Harry Stack Sullivan in America.
Melanie Klein adapted psychoanalytical techniques for use with very young children. She interpreted their play and originated the ‘object relations’ school of psychoanalysis. The ‘object’ refers both to an emotionally significant person (e.g. the mother), to parts of that person (e.g. the mother’s breast) and, most importantly, to their internal psychological representation. Klein’s language is excessively dramatic, emphasizing strong instinctual feelings of love and hate. Initially objects are either loved or hated, and ambiguity is resolved by ‘splitting’ into good and bad parts. Only later can both good and bad feelings be experienced simultaneously or remorse felt. Klein referred to this sequence as the change from the ‘paranoid-schizoid position’ to the ‘depressive position.’ The starkness of Klein’s theory is difficult to accept uncritically, but has been widely influential. For an outline of Klein’s theories, see Segal (1963).
Attachment theory originated in the work of John Bowl by, a British analyst. The theory is not based on drives, instincts, or object relations, but on the proposition that infants need a secure relationship with their parents, and that insecure attachments can lead to difficulty in establishing relationships later, and to emotional problems. Bowlby’s ideas had a considerable effect on the care of children, such as the need to maintain contact with the parents when a child is admitted to hospital. For a review of the historical development of attachment theory, see Holmes (2000).
Brief psychodynamic psychotherapy. Ferenczi saw the need to develop treatments shorter than psychoanalysis. He did this by setting time limits, making the role of the therapist less passive, and planning the main themes of treatment. These innovations have found their way into the brief dynamic psychotherapy that is used today (see p. 589).
Later developments. Recent developments have continued the trend towards briefer treatment, attending more to the patient’s current problems than to those in the past. There are two main types:
1. Interpersonal therapy (see p. 578), developed by Klerman and Weissman, is directed to current interpersonal problems.
2. Cognitive analytic therapy (see p. 590), developed by Ryle, uses cognitive therapy techniques within a framework of psychodynamic understanding (Ryle and Kerr, 2002).
The development of cognitive–behaviour therapy
Behaviour therapy. Interest in a treatment based on scientific psychology can be traced to the focus of Janet (1925) on re-education, the use by Watson and Rayner (1920) of learning principles in the treatment of children’s fears, and aversion therapy for alcoholism. Psychologists in the 1930s at the Maudsley Hospital in London began to use learning principles to devise treatment for patients with phobic disorders. Joseph Wolpe in South Africa published Psychotherapy by Reciprocal Inhibition (Wolpe, 1958). He described a widely applicable treatment for neurotic disorders, based on learning theory and making use of relaxation. In the USA, Skinner (1953) proposed operant conditioning in the treatment of psychiatric disorders.
Wolpe’s ideas were adopted in the UK, where they fitted well with the initiatives at the Maudsley Hospital. Skinner’s ideas were initially more influential in the USA. These approaches converged, and practice in the two countries is now similar.
From the beginning there was a strong emphasis on the evaluation of the new treatment methods. The first clinical trial (desensitization versus individual and group dynamic psychotherapy) was reported in 1978 (Gelder et al., 1978). Several trials followed, with increasing sophistication, resulting in a strong evidence base for the behavioural methods in current use.
Cognitive therapy began with the work of A. T. Beck, a US psychiatrist who was dissatisfied with psychoanalytical psychotherapy for depressive disorders. Beck noted recurring themes in the thinking of depressed patients, and he concluded that these themes were an essential part of the disorder and had to be changed by challenging them in specific ways (see p. 585).
A second source of cognitive therapy was from US psychologists dissatisfied with operant conditioning and its ‘black-box’ approach. Meichenbaum (1977) proposed that the recurrent thoughts of people with emotional disorders played a part in maintaining their distress, and suggested how these thoughts might be controlled.
Cognitive–behaviour therapy. These cognitive approaches were integrated with behaviour therapy to produce cognitive–behaviour therapy. The strong evidence base, clearly described procedures, and relatively brief treatment time of cognitive–behaviour therapies have made them the preferred psychological treatment for many disorders.
Classification of psychological treatments
There are so many kinds of psychological treatment that it is useful to group them in a simple classification, and several of these have been proposed. Three will be considered, with a simple scheme to locate their use in most healthcare systems.
1. Classification by technique:
• Other (e.g. systems theory).
2. Classification by number of patients taking part:
• Individual therapy (involving one patient) may be used when the treatment needs to be tailored to the particular problems of the patient.
• Couple therapy may be used when relationship problems are an important contributory cause of psychiatric disorder.
• Family therapy may be used when the difficulties, particularly of a child or adolescent, are part of a wider problem in the family.
• Small and large group therapy may be used when several patients require similar treatment (e.g. exposure treatment for agoraphobia), or when the contributions of other group members will be helpful (e.g. to help alcohol abusers view their problems more objectively).
These first two types of classifications can be combined—for example, individual cognitive–behavioural or psychodynamic group therapy.
Uses of psychotherapy within a publicly funded mental health service
Psychological treatment is the principal treatment for some psychiatric disorders, used alone or with medication. Counselling, crisis intervention, and cognitive–behaviour therapies are used in this way when they have been shown to be effective in clinical trials. Dynamic psychotherapy, because there is inadequate evidence of its efficacy, is now used mainly to modify factors such as low self-esteem, and is currently used in group treatments for personality disorder. ‘Subthreshold’ conditions are now generally offered counselling, and psychodynamic treatment for them now occurs mainly in private practice.
Consideration of these uses within a public health service leads to a third classification:
• Simple psychological aspects of all healthcare. These are methods of counselling to help individuals to adjust to stressful situations or confront difficult decisions. These overlap the routine doctor–patient relationship.
• Moderately complex and provided by most mental health professionals. This includes the simpler cognitive–behaviour therapy and brief dynamic psychotherapies. These treatments are usually part of a management plan that includes medication and social measures.
• Highly complex and provided by formally trained therapists. This group includes the more complex psychodynamic and cognitive–behaviour therapies. These are used to treat more severe or complex disorders, alone or as part of a wider plan of management.
Common factors in psychological treatment
Different psychological treatment methods achieve results which are similar to each other and which are greater than placebo. The features that the psychotherapies share may be more important than their differences. Jerome Frank (1967) proposed that the important common features are the therapeutic relationship, listening sympathetically, allowing the release of emotion, providing information, providing a rationale for the patient’s condition, restoring morale, using prestige suggestion, and forming a relationship. These features are listed in Box 20.1.
Transference and counter-transference
All therapeutic relationships run the risk of becoming intense. These strong relationships were labelled ‘transference’ and ‘counter-transference’ by Freud, who considered that their force derived from the earlier important relationships that were ‘transferred’ on to them. Transference and counter-transference develop to some extent during all psychological treatments, and therapists overlook them at their peril.
Box 20.1 Common factors in psychotherapy
The therapeutic relationship. This is generally thought to be the most important of the common factors in psychotherapy. However, it may become too intense, with resulting problems (see text).
Listening. By listening attentively, the therapist shows concern for the patient’s problems and begins to develop the helping relationship in which the patient feels understood.
Release of emotion. Emotional release can be helpful at the beginning of treatment, but repeated release is seldom useful. Intense and rapid emotional release is called abreaction.
Restoration of morale. Many patients have suffered repeated failures, and no longer believe that they can help themselves. By improving their morale, the therapist helps the patient to begin to help him- or herself.
Providing information. Distressed patients may remember little of what they have been told about their condition because their concentration is poor. Information should be as simple as possible and expressed clearly. It may be necessary to explain important points more than once, or to write them down.
Providing a rationale. All forms of psychological treatment provide reasons for the patient’s condition, and this adds to the patient’s confidence. The reasons may be stated directly by the therapist (as in short-term psychotherapy), or suggested indirectly through questions and interpretations (as in much long-term psychotherapy).
Advice and guidance. These are part of all psychotherapy. In brief therapies, the advice and guidance are given directly. In long-term treatments the patient is made to seek the answers, but may still be guided—less obviously—in deciding which of them are right.
Suggestion. Although, with the exception of hypnosis, suggestion is not deliberately increased in psychological treatments, all psychological treatment contains an element of suggestion. This suggestive element contributes to improvement in the early stages of treatment, but does not usually last long.
Transference often becomes increasingly intense as treatment progresses, and is especially strong when patients reveal intimate personal problems. The patient may transfer to the therapist their feelings and attitudes from previous relationships, such as those towards their parents. Transference can be positive, with warm feelings, or negative, with critical or hostile feelings. Freud originally thought that the development of transference was an impediment to therapy, but eventually considered it, and its resolution, to be an essential part of any successful treatment.
Counter-transference. In psychotherapy, therapists have to be genuinely concerned about their patients, yet remain impartial and professional. They cannot always achieve this ideal, and may develop strong feelings (positive or negative) about the patient. Analysts debate whether the term counter-transference should be restricted to ‘neurotic’ or distorted responses, or whether it can include reasonable and rational responses. Transference problems may arise from excessive dependency on or idealization of the therapist. Dependency may make it difficult to end treatment, when a resurgence of symptoms can undermine a healthy separation. However, dependency is a normal feature of therapy and, if contained early enough, such difficulties can usually be prevented.
Counter-transference problems arise when therapists become inappropriately involved in their patients’ problems or inappropriately angry with them. Training for intensive psychotherapy often includes a period of psychotherapy to sensitize future therapists to the strength of transference and counter-transference. It is why ongoing supervision is considered necessary.
Counselling and crisis intervention
In everyday usage, the word ‘counselling’ denotes the giving of advice. Here it denotes a wider procedure concerned as much with emotions as with knowledge. There are many techniques of counselling for a variety of problems, and in a variety of settings (e.g. general medical practice, as part of psychiatric care, and in a student health service).
Counselling incorporates the non-specific factors shared by psychotherapies (see Box 20.1). The relationship between the counsellor and the person who is being counselled is paramount, but the relative importance of giving information, allowing the release of emotion, and thinking afresh about the situation, vary. In the past the client-centred approach dominated, in which the counsellor takes a passive role. They give little information and largely restrict their interventions to reflections on the emotional content of the client’s utterances or simply repeating the last statement with an interrogative tone. They rarely seek clarification of facts, but rather they may say, for example, ‘That seems to make you angry’ (reflection of feelings) or ‘You were disappointed’ (repeating for clarification the last statement). This approach has been largely replaced in secondary mental healthcare by the more structured and focused procedures, which are generally agreed to be more rapidly effective. Client-centred approaches remain very commonly used by independent counsellors.
Approaches to counselling
Problem-solving counselling is highly structured, and is suitable when patients’ problems are related to stressful circumstances. It is widely applicable to conditions in which life problems are exacerbating or maintaining other disorders. Basic counselling is combined with a systematic approach to the resolution of problems. The patient is helped to:
• identify and list problems that are causing distress
• consider courses of action that might solve or reduce each problem
• select a problem and course of action that appear feasible and likely to succeed
• review the results and then either select another problem if the first course of action has succeeded, or another course of action if the first one has not succeeded.
Problem-solving counselling has been shown to be effective for less severe forms of mood disorder. For a review, see Mynors-Wallace et al. (2000).
Interpersonal counselling was developed by Klerman et al. (1987) from interpersonal therapy (described on p. 578), and has many similarities to the problem-solving approach. Attention is focused on current problems in personal relationships within the family, at work, and elsewhere. These problems are considered under four headings—loss, interpersonal disputes, role transitions, and interpersonal deficits. Using a problem-solving approach, the therapist encourages patients to consider alternative ways of coping with these difficulties, and to try these out between sessions. It has been shown to be effective for patients in primary care presenting with minor mood disorders (Klerman et al., 1987).
Psychodynamic counselling places more emphasis on the influence of past experience, mediated significantly through unconscious processes. It assumes that previous relationships leave lasting traces which affect self-esteem and influence current relationships. The patient’s emotional reactions to the counsellor (transference) are used to understand problems in other relationships. In student health centres its developmental approach fits well, but it has not been formally evaluated.
Counselling for specific purposes
This approach is used for survivors of disasters, who are encouraged to recall the distressing events. The emphasis is on emotional release, and on ways of coping with the immediate problems. Evidence from clinical trials is discouraging, suggesting that this approach may prolong ruminations (Mayou et al., 2000) and distract from essential social supports and the traditional advice to ‘get back on the horse as soon as possible.’
Counselling for relationship problems
Couples are encouraged to talk constructively about problems in their relationship. The focus is on the need for each partner to understand the point of view, needs, and feelings of the other, and to identify positive aspects of the relationship as well as those that are causing conflict. The provision of a ‘safe space’ in which to explore is particularly prominent in this form of counselling, which can otherwise easily spiral into mutual recrimination.
Grief counselling draws heavily on following the identified stages of normal grief (see p. 171). It combines an opportunity for emotional release (including anger), information about the normal course of grieving, and sensitive encouragement about viewing the body and disposing of clothing. It also involves advice on practical problems of living without the deceased person.
Counselling about risks
Examples include genetic counselling and counselling about the risks of sexually transmitted disease. It focuses on giving information about the risks, providing an opportunity for reflection on the impact of the potential outcomes, and helping the patient to decide how best to respond.
Counselling in primary care
In primary care, many patients are referred to practice counsellors and IAPT (Improving Access to Psychological Therapies) workers who have received a relatively limited training but often have no background in the medical, nursing, or social work professions. Counsellors use various methods of brief treatment, although most often they employ non-directive Rogerian approaches, usually for a limited number of sessions (about seven) (Sibbald et al., 1996a). Although very popular, evidence for the effectiveness of counselling in primary care is limited (Chilvers et al., 2001; Bower et al., 2003). IAPT workers are trained in basic cognitive–behaviour therapy.
Crisis intervention can be used either to help patients to cope with a crisis in their life or to use the crisis as an entry to longer-term problems. The approach has been used after the break-up of relationships and in the aftermath of natural disasters such as floods and earthquakes. Crisis intervention, which originated in the work of Lindemann (1944) and Caplan (1961), draws on Caplan’s four stages of coping:
1. emotional arousal with efforts to solve the problem
2. if these fail, greater arousal leading to a disorganization of behaviour
3. trials of alternative ways of coping
4. if there is still no resolution, exhaustion and decompensation.
Crisis intervention seeks to limit the reaction to the first stage, or if this has been passed before the person seeks help, to avoid the fourth stage.
Problems leading to crisis
These problems most often include the following:
• loss and separation, such as bereavement or divorce, but also during severe illness
• role changes, such as marriage, parenthood, or even a new job
• relationship problems, such as those between sexual partners, or between parent and child
• conflicts, usually when faced with impossible choices.
Table 20.1 Crisis intervention
Treatment is immediate, brief, and collaborative
Focus on current problems
Consider future coping methods
Crisis intervention methods
The methods used in crisis intervention (see Table 20.1) generally resemble interpersonal counselling (see p. 576) and problem-solving counselling (see p. 576), although with a greater emphasis on reducing arousal. Treatment starts as soon as possible after the crisis and is brief, usually consisting of a few sessions over a period of days or at most a few weeks. The focus is on current problems, although relevant past events are also considered. High levels of emotional arousal interfere with problem solving, and the first aim of treatment is to reduce arousal. Reassurance and ventilation of emotions are usually effective, but anxiolytic medication may be needed for a few days. The second stage of crisis intervention resembles problem-solving counselling. It is most valuable for people facing major but transitory difficulties—for example, after deliberate self-harm (Bridgett and Polak, 2003).
Supportive psychotherapy is one of the most difficult but also one of the most important skills that any psychiatrist must acquire. It is used to relieve distress or to help a person to cope with enduring difficulties such as chronic mental or physical illness, and as part of the care of the dying (see p. 170). Supportive therapy is based on the common factors of psychological treatment (see Box 20.1). Its basic elements are listed in Table 20.2, and include a therapeutic relationship, listening, allowing the release of emotions, explaining, encouraging hope, and persuasion. Each of the various components will be considered briefly in turn.
• The therapeutic relationship. A trusting and supportive relationship is central in sustaining patients with long-term difficulties. It is important to avoid excessive dependence, but this is most often achieved by a realistic and mature acceptance of the need for dependence. After all, the patient is seeing you because they ‘need’ you. A fear of acknowledging the importance of relationships and healthy dependence (we all achieve independence through the successful resolution of our dependence) carries the greatest risk for excessive and pathological dependence.
• Listening. As in all forms of psychological treatment, the patient should feel that they have their doctor’s full attention and sympathy while he is with them, and that their concerns are being taken seriously.
• Information and advice are important, but their timing should be considered carefully. Information should be accurate, but it is not necessary to explain everything during the first session. Indeed, the patient may need to receive information gradually, giving them time to work through it. Most patients indicate, directly or indirectly, how much they wish to be told.
• Emotional release can be helpful in the early stages of supportive treatment.
• Encouraging hope is important, but unrealistic reassurance can destroy a patient’s confidence in their carers. Reassurance should always be specific, offered only when the patient’s concerns have been fully understood. Even with the most difficult problems, a positive approach can often be maintained by encouraging the patient to build on their assets and opportunities.
• Persuasion. It is sometimes appropriate for doctors to use their powers of persuasion to help patients to take some necessary step—for example, to continue to cope despite a temporary exacerbation of their condition.
Table 20.2 Basic procedures of supportive treatment
Develop a therapeutic relationship
Listen to the patient’s concerns
Inform, explain, and advise
Allow the expression of emotion
Review and develop assets
Supportive treatment need not be provided exclusively by health professionals. Self-help groups give valuable support to some patients and to relatives. This type of treatment can be more effective because it is given by people who have struggled with the same problems as the patient. Support groups vary enormously, and it is important have some familiarity with a particular group before recommending it. For an account of supportive treatment, see Bloch (1986).
Interpersonal psychotherapy was developed as a structured psychological treatment for the interpersonal problems of depressed patients (Klerman et al., 1984). The method has a wider application to other disorders in which similar problems are maintaining behaviour—for example, eating disorders. It is characterized by its approach rather than its techniques, which overlap with those of other kinds of psychotherapy.
The treatment is highly structured. The number and content of treatment sessions are planned carefully. The initial assessment period lasts from one to three sessions. Interpersonal problems are considered under the following four headings:
1. bereavement and other loss
2. role disputes
3. role transitions
4. ‘interpersonal deficits’ such as loneliness.
Each problem is considered using specific situations, and alternative ways of coping are evaluated. Clear goals are set and progress towards them is monitored. New coping strategies are tried out in homework assignments. In the middle phase of treatment, specific methods are used for each of the four kinds of problem listed above. For grief and loss, the methods resemble grief counselling (see p. 576). For interpersonal disputes and role transitions, patients are helped to identify clearly the issues in the dispute, as well as any differences between their own values and those of the relevant others. They are helped to recognize their own contributions to problems that they ascribe to that person. Interpersonal deficits are addressed by analysing present relationship problems and previous attempts to overcome them, and then discussing alternatives. In the final two or three sessions, future problems are anticipated and considered.
Several clinical trials have shown that interpersonal therapy is effective for depressive disorders in adults and adolescents (Mufson, 2004), dysthymia (Markowitz, 2003) and bulimia nervosa. For an account of interpersonal therapy, see Blanco and Weissman (2005).
All psychiatric disorders have cognitive and behavioural components, and these features have to change if the patient is to recover. With other treatments, change comes about indirectly—for example, as mood improves with antidepressant therapy, or as the origins of the disorder are understood better with psychotherapy. Cognitive–behaviour therapy aims to change cognitions and behaviour directly. Unlike dynamic psychotherapy, cognitive–behaviour therapy is not concerned with the ways in which the disorder developed in the past, but with the factors that are maintaining it now.
Behaviour therapy is concerned with factors that provoke symptoms or abnormal behaviour. For example, in bulimia nervosa, episodes of excessive eating may be provoked by situations that cause the patient to feel inadequate. One of the most frequent maintaining factors is avoidance. This is particularly important in phobic and anxiety disorders, in which it prevents the normal extinction of the anxiety response. Many behaviours are maintained by their consequences. For example, escape from an anxiety-provoking situation is followed by a reduction in anxiety, and this reduction reinforces the phobic avoidance. Increased attention is another powerful reinforcer of behaviour. For example, a child’s noisy and unruly behaviour will be reinforced if his parents pay more attention to him when he behaves in this way than when he is quiet and well behaved.
Cognitive therapy generally focuses on two kinds of abnormal thinking—intrusive thoughts (‘automatic thoughts’) and dysfunctional beliefs and attitudes (‘dys-functional assumptions’). Intrusive thoughts provoke an immediate emotional reaction, usually of anxiety or depression. Dysfunctional beliefs and attitudes determine the way in which situations are perceived and interpreted.
Three factors are thought to maintain dysfunctional beliefs and attitudes.
1. Attending selectively to evidence that confirms them, and ignoring or discounting evidence that contradicts them. For example, patients with social phobias attend more to the critical behaviour of others than to signs of approval.
2. Thinking illogically in a number of ways, of which three common ones are described in Box 20.2.
3. Safety-seeking behaviour, which occurs because it is believed to reduce an immediate threat, but in fact in the long term perpetuates the fear. A patient who fears that she will faint during a panic attack may tense her muscles when anxious, believing that this prevents fainting, and therefore continues to fear that she may faint in the future.
Box 20.2 Examples of illogical thinking
Over-generalization. Patients draw general conclusions from single instances (e.g. ‘He does not love me, so no one will ever love me’).
Selective abstraction. Patients focus on a single unfavourable aspect of a situation and ignore the favourable aspects.
Personalization. Patients blame themselves for the consequences of the actions of other people.
All-or-nothing thinking. Patients view people or situations in ‘black-and-white’ terms (e.g. a person is seen as wholly good or wholly bad, rather than having a mixture of good and bad qualities).
General features of cognitive–behaviour therapy
Certain features characterize cognitive–behavioural treatments.
• The patient is an active partner. The patient takes an active part in treatment, with the therapist acting as an expert adviser who asks questions, and offers information and guidance.
• Attention to provoking and maintaining factors. The patient keeps daily records to identify factors that precede or follow the disorder and which may be provoking or maintaining it. This kind of assessment is sometimes called the ABC approach, the initials referring to Antecedents, Behaviour, and Consequences.
• Attention to ways of thinking, revealed by recording thoughts associated with the behavioural or emotional disturbance, the situations in which these thoughts appear, and the accompanying mood.
• Treatment as investigation. Therapeutic procedures are usually presented as experiments which, even if they fail to produce improvement, will help the patient to find out more about the condition.
• Homework assignments and behavioural experiments. Patients practise new behaviours between sessions with the therapist, or carry out experiments to test explanations suggested by the therapist. Box 20.3contains an example of a behavioural experiment.
• Highly structured sessions. At each session, an agenda is agreed, and progress since the last session is reviewed, including any homework. New topics are considered, the following week’s homework is planned, and the main points of the session are summarized.
• Monitoring of progress. Assessment of progress does not rely solely on the patient’s verbal account, but typically includes the checking of daily records kept by the patient, and sometimes of formal rating scales.
• Treatment manuals are often available that describe the procedures and the way in which they are to be applied. Manuals ensure that different therapists use procedures that are closely similar to those shown to be effective in clinical trials.
Assessment for cognitive–behaviour therapy
Topics to be covered
As well as a full psychiatric history, certain additional topics are addressed (see Table 20.3). For each of the presenting problems, the interviewer obtains an account of the antecedents, the behaviour, and the consequences (the ABC approach described above). Note that the term ‘behaviour’ is used to include thinking and emotion, as well as actions. By considering the sequence ABC on several occasions, regular patterns of thinking and responding are identified. The assessor is particularly concerned with the patient’s reasons for holding their beliefs, as this knowledge is essential when planning how to arrange experiences that will negate and change those beliefs.
Sources of information for the assessment
Self-monitoring. The patient records their thoughts, behaviours, and associated factors over a period of days or weeks. The record is made as soon as possible after the events, so that important details are not forgotten. The record sheet usually has columns for symptoms, thoughts, emotions, and actions, and the day and time at which they occurred. Events immediately preceding the problem are noted, as well as those occurring at the time and afterwards.
Box 20.3 An agoraphobic patient’s record of a behavioural experiment
Situation: Shopping in a crowded supermarket.
My predictions: I shall panic and feel dizzy. Unless I tense my stomach muscles and breathe deeply, I shall faint.
Experiment: When anxious, do not tense stomach muscles or breathe deeply.
Outcome: I did panic quite badly. I felt dizzy, but less so than usual. I did not faint.
What I learned: I did not faint even though I had a severe panic, and I did nothing to prevent fainting. I seem to be wrong in thinking I shall faint whenever I panic. Also tensing and deep breathing may not be having the effect I supposed. My therapist could be right in thinking that deep breathing makes me feel more dizzy.
What I should do next: Repeat the experiment next time I go shopping.
Table 20.3 Topics to be considered during assessment for cognitive–behaviour therapy
1. A description of each problem, including behaviour, thoughts, and emotions associated with it
• Where it occurs most often
• Common prior events
• The patient’s response to these events
• What follows the problem
2. Factors that alleviate or worsen the problem
3. Maintaining factors
• Safety behaviours (see text)
• Selective attention
• Ways of thinking
• The responses of others
Observations during treatment sessions. The patient may be asked to imagine situations in which problems arise, and to report the accompanying thoughts and emotions. Also, symptoms resembling those of the disorder may be induced (e.g. panic-like symptoms produced by hyper-ventilation), and the accompanying thoughts and emotions noted. This technique can be used when treating panic disorder (see p. 585).
Special interviewing. Some patients need help to become aware of their maladaptive beliefs. Laddering involves a series of questions, each about the answer to the previous question. For example, a patient with an eating disorder might be asked what would happen if she were to gain weight, and she answers that she would lose her friends. To the question ‘Why?’ she might reply that she would be unlikeable. To a further question ‘Why?’ she might say that only thin people are attractive and popular.
The information obtained in these various ways is combined with the usual psychiatric history in a formulation consisting of:
• the type of events that provoke symptoms (e.g. opening a conversation)
• any special features of these events (e.g. speaking to a man of the same age)
• background factors (e.g. an excessively critical parent)
• maintaining factors, including avoidance, safety behaviours, and ways of thinking.
The formulation is guided by the cognitive model of the disorder (e.g. the cognitive model of panic disorder; see p. 584). The therapist discusses the formulation with the patient and may build it up, step by step, as a diagram on paper or on a whiteboard. The formulation is modified as necessary as a result of this discussion.
There are many behavioural techniques, some for a single disorder (e.g. the enuresis alarm, see p. 583), and others that can be used for a variety of disorders (e.g. exposure). Here we describe the more commonly used methods. Evidence for them is considered in the relevant chapters for the particular disorders.
This is the simplest behavioural technique, which is mainly useful for sub-threshold states of anxiety, for stress-related disorders such as initial insomnia (Viens et al., 2003), and for mild hypertension (Yung and Keltner, 2000). Originally, in ‘progressive relaxation’, patients were trained to relax individual muscle groups one by one, and to regulate their breathing (Jacobson, 1938). Simpler approaches, such as applied relaxation, are used in anxiety disorders with good effects (Öst and Breitholz, 2000). Relaxation can be learned in part from pre-recorded instructions or in a group, saving therapist time. However, relaxation has to be practised regularly, and many patients lack the motivation to do this.
Exposure is used to reduce avoidance behaviour, especially in the treatment of phobic disorders. For simple phobias it is often sufficient to use exposure alone, but for complex phobic disorders exposure is usually combined with cognitive procedures (see p. 584). Exposure can be carried out in practice (i.e. in the actual situations that provoke anxiety) or in imagination (i.e. while imagining the phobic situations vividly enough to induce anxiety). Exposure can be gradual, progressing through a series of increasingly difficult situations (desensitization), or abrupt and intensive (flooding). In practice, exposure is usually paced between these two extremes, preferably in practice rather than in imagination.
In desensitization the patient is helped to:
1. construct a hierarchy by making a list of situations that provoke increasing degrees of anxiety. About 10 items are chosen with an equal increment of anxiety between them. The severity of steps can be modified (e.g. if the person is accompanied). If no common theme exists between stressful situations, two or more hierarchies can be constructed
2. enter or imagine entering the situations on the hierarchy until this can be done without anxiety
3. use relaxation while entering or imagining the situation so as to reduce the anxiety response, and make the imagery more vivid
4. repeat this procedure with each item on the hierarchy.
When exposure to the actual situation is impractical (e.g. flying phobia), desensitization in imagination is used.
In flooding, the patient enters situations near the top of the hierarchy from the start of treatment, and remains there until the anxiety has diminished. The process is repeated with other near-maximal stimuli. Because many patients find the experience distressing and the results have not been shown to be better than those obtained with desensitization, flooding is seldom used.
Exposure in everyday practice
Sessions last for about 45 minutes. The patient enters a feared situation every day, either alone or with a relative or friend. Usually anxiety diminishes with each exposure. If it does not, this may be because treatment started too high on the hierarchy, so should restart from a lower item. Some patients fail to progress because they disengage from anxiety-provoking situations by thinking of other things. If the patient can reduce this defensive behaviour, progress can usually be made.
Exposure with response prevention
This is a treatment for obsessional rituals. The procedure is based on the observation that the urge to carry out rituals decreases if the rituals can be resisted for long periods (usually about an hour). The steps in the procedure can be summarized as follows.
1. The therapist explains the rationale for treatment and agrees targets for exposure with the patient. For example, a target might be to touch a ‘contaminated’ object such as a door handle, and not to wash their hands for the next hour. A more advanced target might be to do all the household cleaning without washing their hands until the task is completed. Patients need to feel confident that every task will be agreed in advance and that they will never be faced with the unexpected.
2. The therapist may demonstrate the necessary exposure him- or herself. This procedure is known as modelling.
3. At first the therapist accompanies and supports the patient while they strive to prevent the rituals; later the patient does this on their own.
4. When the necessary restraint has been achieved, the urge to carry out rituals is made greater by persuading the patient to enter situations that provoke this urge. Since these situations have previously been avoided, this procedure is called exposure.
The obsessional thoughts that accompany rituals usually improve as the rituals are brought under control. Obsessional thoughts that occur without rituals are more difficult to treat. Habituation training is a form of mental exposure treatment in which patients dwell on the obsessional thoughts for long periods or listen repeatedly to a recording of the thoughts spoken aloud for an hour or more. (A second technique for treating obsessional thoughts, known as thought stopping, is described in the section on distraction techniques on p. 584.)
Social skills training
Some aspects of social behaviour include skills that can be learned—for example, making eye contact, or starting a conversation. These skills can be improved through modelling, guided practice, role play and video feedback. The training is mainly useful for socially anxious people, and within rehabilitation for people with chronic mental disorders.
Assertiveness training is a form of social skills training in which patients practise appropriate self-assertion—for example, when being ignored by a gossiping shop assistant. By a combination of coaching, modelling, and role reversal, patients are encouraged to practise appropriate verbal and non-verbal behaviour, and to judge the level of self-assertion that is appropriate to various situations.
In this form of social skills training, patients are helped to:
• identify situations that lead to anger
• identify attitudes that lead to anger that is out of proportion
• identify factors that reduce restraints on anger, especially the use of alcohol
• discover and practise alternative ways of dealing with situations that provoke anger—for example, delaying their response until anger can be brought under control (‘count to 10’).
All behavioural treatments aim to increase patients’ control over their own behaviour. Self-control techniques attempt to do this directly without the intermediate step of changing thoughts or emotions as in cognitive therapy. Self-control techniques are based on operant conditioning principles, and on the studies by Bandura (1969) of the role of self-reward in the control of social behaviour. Overeating and excessive smoking are examples of target behaviours. Self-control training is usually part of a wider cognitive–behaviour programme—for example, in the treatment of eating disorders (see p. 587).
Self-control treatment has three stages:
1. Self-monitoring. Daily records are kept of the problem behaviour and the circumstances in which it arises. For example, patients who overeat record what they eat, when they eat, and any associations between eating, stressful events, and mood states. Keeping such a record is in itself a powerful stimulus to self-control, as it brings home the severity of the problem. These records are subsequently used to assess progress.
2. Self-evaluation. Achievements to be rewarded are agreed with the patient, and progress is monitored by the patient.
3. Self-reward. It is often useful to devise a system of reward points that can be accumulated in order to earn a material reward—for example, a week without smoking may be rewarded by going out for dinner.
Contingency management, like self-control techniques, provides rewards for desired behaviour and removes reinforcement from undesired behaviour. However, instead of relying on self-monitoring and self-reinforcement, in contingency management another person monitors the behaviour and provides the reinforcers. The latter are usually social reinforcers, such as indications of approval or disapproval, or enjoyable activities earned by accumulating points. Contingency management in the form of token economies was used mainly in the treatment of children and people with learning disability in residential settings, but is now seldom used because of its limited effect and generalizability. More recently, direct financial rewards have been given for changes in behaviour. This has been particularly helpful in supporting treatment adherence in substance misusers and marginalized groups (e.g. TB treatment in the homeless, antenatal care, smoking) (Petry and Simcic, 2002). Financial incentives for adherence to antipsychotic maintenance management are currently being researched (Priebe et al., 2009).
Contingency management involves four stages.
1. Define and record the behaviour. The behaviour to be changed is defined and another person (usually a nurse or a parent) is trained to record it. For example, a mother might count the number of times a child with learning difficulties shouts loudly.
2. Identify the stimuli and reinforcements. Stimuli for the behaviour are identified by recording the events that regularly precede it. Reinforcers are identified by recording the events that immediately follow the behaviour. Those involved may be quite unaware of their role in stimulating or reinforcing such behaviours.
3. Change the reinforcement. Reinforcement is directed away from the problem behaviours and towards desired behaviours. For example, parents are helped to attend less when their child shouts and more when he is quiet—always a difficult thing to keep up.
4. Monitor progress. Records are kept of the frequency of the problem behaviours and of the desired behaviours.
Contingency management is used alone and also as part of a wider programme—for example, in the treatment of substance abuse (Petry and Simcic, 2002).
This behavioural treatment was developed specifically for nocturnal enuresis (see p. 667). In the original ‘pad and bell’ method, two metal plates forming part of a circuit with a battery and a buzzer were placed under the sheets. If the child passed urine while asleep, a current flowed between the plates, activating the buzzer. Nowadays a small sensor is attached to the pyjamas. The noise of the alarm wakes the child, who must then rise to empty his bladder and, if necessary, change the bed sheet. After several repetitions the child begins to wake before his bladder empties involuntarily. The waking from sleep before passing urine can be understood as the result of classical conditioning. It is less easy to understand how the treatment leads to an uninterrupted dry night. The procedure is considered further on p. 667.
Complex behavioural techniques
Habit reversal is a complex procedure that is generally used to treat tics, Tourette’s syndrome, and stuttering. The classical treatment has five components—training in becoming aware of the onset of the behaviour, monitoring the behaviour, training in initiating competing responses that are incompatible with the behaviour, relaxation, and social support. Positive effects have been reported using a simplified procedure (Himle et al., 2006).
Eye movement desensitization and reprocessing (EMDR)
This treatment was developed for post-traumatic stress disorder. It has three components:
• exposure using imagined scenes of the traumatic events
• a cognitive component in which the patient attempts to replace negative thoughts associated with the images with positive ones
• saccadic eye movements induced by asking the patient to follow rapid side-to-side movements of the therapist’s finger.
EMDR remains controversial, particularly with regard to whether the eye movements contribute to its efficacy (Russell, 2008). A recent review (Silver et al., 2008) suggests that it is effective, although the quality of the evidence is relatively poor.
Behavioural techniques that are no longer in general use
Biofeedback has not been proved to add to the effects of relaxation alone. Aversion therapy, one of the earliest behavioural techniques, was developed in the 1930s as a treatment for alcohol dependence. Negative reinforcement was used to suppress unwanted behaviour. Its effects are temporary, and it was criticized as being more of a punishment than a treatment.
Four methods are commonly used to bring about cognitive restructuring (i.e. change in cognitions).
1. Distraction, or focusing attention away from distressing thoughts. This is done by attending to something in the immediate environment (e.g. the objects in a shop window), by engaging in a demanding mental activity (e.g. mental arithmetic), or by producing a sudden sensory stimulus (e.g. snapping a rubber band on the wrist), called ‘thought stopping.’
2. Neutralizing. The emotional impact of anxiety-provoking thoughts can be reduced by rehearsing a reassuring response (e.g. ‘My heart is beating fast because I feel anxious, not because I have heart disease’). Patients may carry a ‘prompt card’ on which the reassuring thoughts are written.
3. Challenging beliefs. The therapist produces evidence that contradicts the patient’s beliefs. However, it is generally not sufficient to challenge the beliefs in this logical way because (as noted above) such beliefs often persist because people think in illogical ways. They over-generalize from single instances, and they pay more attention to evidence that supports their beliefs than to evidence that contradicts them (Beck, 1976). Therefore the therapist not only provides information but also attempts to reveal and change the illogical ways of thinking. He does this in two ways—by asking questions such as those shown in Box 20.4, and by arranging behavioural experiments of the kind shown in Box 20.3 (p. 580).
4. Reassessing the patient’s responsibility. Some beliefs persist because the patient overestimates the extent of their responsibility for events that have multiple determinants. Patients can be helped to reassess their responsibility by constructing a pie chart that shows all of the determinants. For example, a mother who feels responsible for ensuring that every member of her family is happy and successful would draw a pie chart showing the contribution of all the factors that determine their state of mind (e.g. events at school or at work, relationships with friends, and even the weather). By allocating appropriately sized sectors to each of these other factors before entering their own contribution, the patient discovers that there is less room for the latter than they had supposed.
Treatments for anxiety disorders
In the treatment of anxiety disorders, cognitive techniques are combined with exposure (see above, p. 581). The importance of exposure is proportional to the amount of avoidance behaviour, being greater in the phobic disorders and less important in generalized anxiety disorders.
Three kinds of cognition are considered in treatment:
1. fear of fear: general concerns about the effects of being anxious (e.g. losing control)
2. fear of symptoms: concerns about specific symptoms (e.g. fears that palpitations are a sign of heart disease)
3. fear of negative evaluation: concerns that other people will react unfavourably to the patient.
The balance of these cognitions varies in different anxiety disorders. In generalized anxiety disorder, fear of fear and general worry predominate (see p. 183). In social phobia, fears of negative evaluation are particularly important, as are concerns about blushing and trembling. In agoraphobia, fear of fear (especially thoughts that the person will faint, die, or lose control) and fears about the symptoms of a panic attack are central. Such cognitions are modified using the techniques outlined above—that is, by giving information, by questioning the logical basis of the fears, and by arranging behavioural experiments.
Information about the physiology of anxiety helps patients to attribute symptoms such as dizziness and palpitations to the correct cause, instead of to physical illness such as heart disease (a common concern). The illogical basis of the fears is discovered by questioning the patient’s own evidence for the beliefs. Behavioural experiments are devised to test the patient’s beliefs and the alternative explanation suggested by the therapist.
Anxiety management is a general treatment for anxiety disorders. It has six stages:
1. Assessment. The patient keeps a diary record of:
• the frequency and severity of symptoms
• the situations in which they occur
• avoidance behaviour.
2. Information about the physiology of anxiety and any other matters that will correct misconceptions.
3. Explanation of the various vicious circles of anxiety (see above and Chapter 9).
4. Relaxation training as a means of controlling anxiety.
5. Exposure to situations that provoke anxiety (see above).
6. Distraction to reduce the impact of anxiety-provoking thoughts (see p. 584).
Treatment for panic disorder is focused on the characteristic beliefs, namely that physical symptoms of anxiety are evidence of a serious physical condition, usually heart disease. These beliefs create a vicious circle in which anxiety symptoms such as tachycardia generate additional anxiety, and this further increases the physical symptoms. Treatment consists of the following stages.
1. Explanation of how physical symptoms are part of the normal response to stress, and how fear of these symptoms sets up a vicious circle of anxiety.
2. Record keeping. Patients record the anxious cognitions that precede and accompany their panic attacks.
3. Demonstration. The therapist demonstrates that:
• physical symptoms can provoke anxious cognitions (e.g. by asking the patient to induce such symptoms by over-breathing or strenuous exercise and noting the accompanying thoughts and fears)
• these cognitions can induce anxiety (e.g. by asking the patient to focus their mind on the cognitions and observe the effect).
This demonstration that physical symptoms lead to anxious thoughts, which in turn lead to anxiety, helps to validate the vicious circle account of the aetiology of panic attacks.
4. Safety-seeking behaviours. Attention is given to safety behaviours, and to any dysfunctional beliefs that make ordinary situations stressful (see p. 579).
5. Behavioural experiments are used to test the patient’s ideas against those proposed by the therapist, and are described by Hackmann (2004).
6. Cognitive restructuring when they experience symptoms, and they observe the effect of this change on the severity of the panic attacks. By repeating this sequence many times they gradually gain control of the panic attacks.
Treatment for post-traumatic stress disorder includes attention to the intrusive visual images that characterize the condition. Patients repeatedly imagine the situations depicted in these images, as they would do in systematic desensitization. They try to change the content in small steps to images that are less distressing. Patients are also helped to integrate and process the fragmentary and distressing recollections of the traumatic events. (Treatment for post-traumatic stress disorder is considered further on p. 163.) For further information about the techniques used, see Mueller et al. (2004).
Overall, cognitive–behaviour therapy is the psychological treatment of choice for anxiety disorders (Olatunji et al., 2010). For a review of the current status and practice, see Clark and Beck (2009).
Cognitive–behaviour therapy for depressive disorders
Cognitive therapy for depressive disorders was developed by A. T. Beck (1976) as the first effective form of cognitive therapy. It is a complex procedure intended to alter three aspects of the thinking of depressed patients—negative intrusive thoughts, beliefs and assumptions that render ordinary situations stressful, and errors of logic that allow these beliefs and assumptions to persist despite evidence to the contrary.
Monitoring is of three kinds.
1. Patients identify intrusive thoughts (e.g. ‘I am a failure’) by writing down their thoughts when their mood is low.
2. Therapists uncover dysfunctional beliefs and assumptions by asking questions such as those shown in Box 20.4. A typical belief of a depressed patient is ‘Unless I always try to please other people, they will not like me.’
3. Patients record their activities and mark each one P if it was pleasurable and M if it was accompanied by a sense of mastery and achievement.
If the patient is severely depressed, the monitoring of thoughts is deferred and attention is focused on activities. The resulting ‘activity schedule’ is used to encourage activities that have been identified as leading to pleasure and mastery. The schedule also helps to bring a sense of order and purpose. At this stage the therapist helps the patient to reduce the need to make decisions, which are difficult for someone who is severely depressed.
If the patient is less severely depressed, treatment begins with an explanation of the cognitive model of depression, and an attempt is made to reduce intrusive thoughts. This is done through distraction (see p. 584) and by rehearsing reassuring alternatives (e.g. ‘Even though I think my work is bad, my boss praised me yesterday’). To help the patient to concentrate on the positive statement, the alternative can be written on a prompt card. As treatment proceeds, more time is spent in challenging depressive cognitions using the techniques outlined in Box 20.5 combined with behavioural experiments. For further information about the devising of these experiments, see Fennell et al. (2004).
Box 20.4 Useful questions for
What is your evidence for this belief?
Is there an alternative way of looking at the situation?
How might other people think if they were in the same situation?
Are you focusing on what you felt rather than on what happened?
Are you forgetting relevant facts? Are you focusing on irrelevant matters?
Are you overestimating how likely this is?
Are you applying to yourself higher standards than you would apply to others?
Are you thinking in black-and-white terms when you should be considering shades of grey?
Are you overestimating your responsibility for the outcome?
What is the worst that could happen? How bad would this be?
What if the worst should happen? Could you cope? Are you underestimating what you can do to deal with the situation?
Adapted from Clark (2000).
The following points are important in relation to cognitive therapy for depression.
• Reviewing evidence. Depressed patients are particularly prone to focus on evidence that supports their negative ideas, and to overlook evidence that contradicts them. The therapist should help the patient to give appropriate weight to the positive evidence.
• Considering alternatives. Depressed patients often reject positive alternatives to their thoughts and beliefs. The therapist can help the patient to consider alternatives by asking questions such as ‘What do you think that another person would think about this situation?’ or ‘What would you think if another person had done what you have done?’ (for additional questions, see Box 20.5). Behavioural experiments are used as another way of challenging beliefs and assumptions.
• Considering consequences. Patients should be helped to see the consequences of thinking negative thoughts. For example, the thought that everything is hopeless may prevent them from attempting even small changes that could accumulate beneficially.
• Considering errors of logic (Box 20.5). The patient should be helped to ask him- or herself questions such as ‘Am I thinking in black and white terms?’, ‘Am I drawing too wide conclusions from this single event?’, ‘Am I blaming myself for something for which I am not responsible?’, or ‘Am I exaggerating the importance of events?’ These questions are asked in relation to specific ideas, beliefs, and situations.
• Considering beliefs. As depression improves, more attention is given to the patient’s beliefs, as abnormal beliefs can lead to relapse. Laddering (see p. 581) can be used to uncover these beliefs. Useful questions include ‘In what ways is this idea helpful?’, ‘In what ways is it unhelpful?’ and ‘What alternatives are there?’
Box 20.5 Logical errors in depressive disorders
Exaggeration: magnifying small mistakes and thinking of them as major failures.
Catastrophizing: expecting serious consequences of minor problems (e.g. thinking that a relative who is late home has been involved in an accident).
Overgeneralizing: thinking that the bad outcome of one event will be repeated in every similar event in future (e.g. that having lost one partner, the person will never find a lasting relationship).
Ignoring the positive: dwelling on personal shortcomings or on the unfavourable aspects of a situation while overlooking the favourable aspects.
• ‘Mindfulness.’ It has been suggested that people who are prone to depression have a cognitive set whereby thoughts and feelings are experienced as events rather than as aspects of the self, and that modifying this set reduces the risk of relapse. Mindfulness-based cognitive therapy is an 8-week programme conducted in groups of 8 to 15 patients (Segal et al., 2002), designed to modify these cognitive routines and reduce the risk of relapse. Findings currently indicate that MBCT in addition to standard care could significantly reduce the relapse rate in patients suffering from major depression (Chiesa and Serretti, 2010). MBCT is now recommended by the National Institute for Health and Clinical Excellence (2009a), but whether the specific ‘mindfulness’ component of treatment has any additive effects over traditional forms of cognitive therapy is currently being examined (Williams et al., 2010).
CBT has proved to be very successful in the treatment of recurrent depression, and is now recommended by the National Institute for Health and Clinical Excellence (NICE).
Cognitive–behaviour therapy for bulimia nervosa
The treatment of bulimia nervosa with cognitive–behaviour therapy is based on the idea that the central problems are excessive concern about shape and weight, and low self-esteem (see Chapter 14). This leads to extreme dieting, followed by binge eating and often by self-induced vomiting and abuse of laxatives and diuretics. This vicious circle can be interrupted by:
• restoring a regular pattern of eating three meals a day
• increasing restraint on binge eating
• discussing ideas about shape, weight, and self-esteem.
The therapist attends first to the disordered pattern of eating before attempting to modify cognitions. He explains the cognitive model and relates it to the patient’s experience. He emphasizes the importance of regular meals, the causal role of long periods of fasting, and the adverse effects of repeated vomiting, and of repeatedly taking laxatives and diuretics. The patient keeps a record of what they eat, when they eat, and when they induce vomiting or take laxatives and diuretics. The situations that provoke binge eating are recorded. With this information, the patient is better able to control the urge to overeat and, subsequently, the bouts of vomiting. The patient takes a number of precautions to help them to control their eating:
• Meals are eaten in a place separate from that in which food is prepared or stored.
• A limited amount of food is available at each meal—for example, two slices of bread are put on the table, rather than a whole loaf.
• A small amount of food is left on the plate and then thrown away, in order to mark the end of the meal.
• When shopping for food, a list is made in advance and purchases are strictly limited to the items and quantities on the list.
The therapist strongly discourages frequent checking of weight and of appearance, as both habits maintain the disorder.
Because patients often binge when they are unhappy, lonely, or bored, they are helped to find other ways of dealing with unpleasant emotions. For example, they might seek out friends, listen to music, or simply go out for a walk. Vomiting usually stops when the binges are under control. The dangers of abuse of laxatives and diuretics are emphasized once more, and the patient is strongly encouraged to safely dispose of all such drugs.
When eating is under better control, attention turns to cognitions. The patient records these together with the eating behaviour. Relevant cognitions are concerned not only with body shape and weight, but also with self-esteem. Examples of these cognitions include the following:
• to be fat is to be a failure
• dieting is a sign of strong will and self-control
• it is necessary to be thin if one is to be happy and successful.
Such beliefs persist because of the illogical ways of thinking (see Box 20.2 on p. 579), namely selective use of evidence, overgeneralization from limited instances, all-or-nothing reasoning, and overestimation of the person’s contribution to events that have multiple causes. Identifying these illogical ways of thinking is not to deny that many of them receive strong social endorsement. The fact that many people agree with such cognitions does not mean that the thinking is not wrong. The questioning used to identify cognitions and illogical thinking resembles that described in Box 20.5. Behavioural experiments are used, as in other forms of cognitive therapy (Cooper et al., 2004). Some patients with bulimia nervosa may have a distorted body image, and this cannot usually be changed directly by cognitive procedures. However, the distortion often diminishes as the other symptoms are brought under control.
Treatment also exists in a self-help format that can be effective with well-motivated patients (see Box 20.6).
For further information about cognitive–behaviour therapy for bulimia nervosa and its effectiveness, see Fairburn et al. (2009a, b).
Cognitive–behaviour therapy has not been shown to be effective in anorexia nervosa. However, some of the underlying principles can be applied in management of that disorder (see p. 357).
Cognitive–behaviour therapy for hypochondriasis
The approach is twofold—first, to identify behaviours that maintain the disorder, and secondly, to change hypochondriacal ideas directly. The relevant behaviours include:
• repeatedly seeking reassurance, which relieves anxiety briefly but reinforces the concerns in the longer term
• checking bodily functions (e.g. measuring the pulse rate)
• checking bodily structure (e.g. palpating for lumps).
Box 20.6 Self-help for bulimia nervosa
• A daily record of eating, binges, and vomiting
• Weighing no more than once a week
Regular planned meals
• Three normal-sized meals a day
• Three small between-meal snacks
• Eat only the planned amount
• Keep other food out of sight
• Keep limited stocks of food
• Take just enough money when buying food
• Urge to vomit declines as binges stop
• Reduce laxatives/diuretics, if necessary, in stages
Find alternatives to binge eating
• List distracting activities
• Try them
Reduce life problems
• Problem-solving counselling (see p. 576)
For further information, see Fairburn (1995).
Hypochondriacal ideas are treated in the same way as anxiety and depressive disorders, using questioning and behavioural experiments (Salkovskis and Bass, 1997).
Cognitive–behaviour therapy for schizophrenia
Two approaches are used. The first aims to help the patient to reduce and cope better with stressors that may be exacerbating the disorder, and to cope better with hallucinations. The techniques for dealing with stressors are similar to those described above, namely identifying and finding ways of dealing with stressful situations. Patients are helped to cope with hallucinations by distancing themselves and repeating statements that neutralize their effects.
The aim of the second approach is to challenge delusions. This approach is directed to secondary delusions, especially those that seem to have developed to explain hallucinations. The therapist encourages the patient to regard the delusions as beliefs rather than facts, and to discuss alternatives. To do this effectively requires a detailed formulation of each patient’s delusions and other beliefs. When questioning the basis of the delusions, the therapist should avoid challenging them directly. Instead he should try to persuade the patient to consider the consequences of holding the delusion and what would be the consequences of thinking in another way. The therapist then tries to reformulate the delusion as a way of making sense of certain experiences, which can be understood in terms of the knowledge the patient had at the time, but should now be reconsidered. The evidence for the effects of cognitive–behaviour therapy in reducing both the distress (Trower et al., 2004) from persistent hallucinations and their rate has been steadily increasing (Wykes et al., 2008). The National Institute for Health and Clinical Excellence (2010b) guidelines on the management of schizophrenia recommend it as a routine provision, although a more recent systematic review paying careful attention to the quality of trials has suggested that its effectiveness may be less than originally proposed (Lynch et al., 2010).
Turkington et al. (2005) have taught the approach to nurses with considerable success, and it is a module in several postgraduate mental health nursing courses (www.thorn-initiative.org.uk).
Cognitive therapy for personality disorder
A. T. Beck suggested that the techniques he had developed for the treatment of depressive disorders could be adapted for personality disorders. He described beliefs and ways of thinking that characterize each type of personality disorder in terms of self-view, the views of others, general beliefs, perceived threats, main strategies for coping, and primary affective responses. Beck also suggested a ‘schema’ characteristic of each type of personality disorder and consisting of statements that can be challenged in treatment. For example, the schema for histrionic personality disorder includes the following statements:
• ‘Unless I captivate people, I am nothing’
• ‘To be happy, I need other people to admire me’
• ‘I must show people that they have hurt me.’
Schemas are challenged using the general techniques of cognitive therapy (see p. 584 and Box 20.5). There is some weak evidence for the value of schema-based cognitive–behaviour therapy in borderline personality disorder (Blum et al., 2008).
Dialectic behaviour therapy for borderline personality disorder
Linehan et al. (1994) developed this treatment for patients with borderline personality disorder who repeatedly harmed themselves. Despite the name, treatment uses cognitive as well as behavioural techniques. The treatment, which is highly structured, is described in a manual. Therapy is intensive, with individual sessions, skills training in a group, and access by telephone to the therapist between sessions. It is delivered by a small team of therapists and lasts for up to a year.
Individual sessions have four elements:
1. cognitive–behavioural techniques (see p. 584), including self-monitoring, and a collaborative style of working with the patient
2. dialectical ways of thinking about problems, such as seeing causality in terms of ‘both/and’ rather than ‘either/or’, and the possibility of reconciling opposites. This approach helps to avoid confrontations with the patient
3. ‘mindfulness’—that is, the practice of detachment from experience
4. aphorisms—that is, phrases that encapsulate the approach (e.g. ‘Although people may not have caused all their problems, they still have to solve them’).
During the sessions, treatment goals are prioritized, dealing first with life-threatening situations, then with matters that could reduce collaboration with treatment, and after that with behaviours that impair quality of life.
Skills training sessions are usually provided in a weekly group lasting for 2 hours or more. Patients learn how to control anger and other strong emotions, how to tolerate distress, how to develop interpersonal skills, and mindfulness. The procedures for teaching these skills are described in a manual.
Telephone contact is designed to help patients get through crises by using the skills that have been learned in the sessions. The hours at which contact will be available are agreed in advance between patient and therapist.
Dialectic behaviour therapy has been claimed to give good results with borderline personality disorder, and has become widely available. The beneficial effects are primarily on behaviour (i.e. reducing self-harming and suicide attempts) rather than on mood and self-esteem.
Individual dynamic psychotherapies
Brief insight-oriented psychotherapy
This kind of psychotherapy seeks to uncover the origins of a psychiatric disorder in early life experience, and seeks for unconscious factors that account for abnormal thinking, emotions, and behaviour. In its usual form, it aims to produce limited but worthwhile changes through weekly sessions for 6 to 9 months. The treatment is focused upon specific problems—hence the alternative term focal psychotherapy. The procedures can be summarized as follows.
The initial assessment is important and should not be hurried. As well as assessing suitability for brief treatment (see below), the aim is to select the problems that are to be the focus of treatment. This focus and the length of treatment are agreed with the patient. Not all problems will be resolved, and this is explained at the start. The therapist explains the general aim of linking past and present behaviour patterns, and that the therapist’s role is to help the patient to find their own solutions, not to do it for them. From the start, an atmosphere is created in which the patient feels involved, listened to, and safe to speak about ideas and fantasies that they may not have previously revealed to anyone.
In subsequent sessions the patient is encouraged to:
• give specific examples of the selected problems, and consider how they thought, felt, and acted at the time
• talk freely about emotionally painful subjects, within the limits of topics agreed with the therapist
• express ideas and feelings even if they seem illogical or shameful
• review their own part in any difficulties that they ascribe to other people
• look for common themes in their problems and their responses to situations
• consider how their present patterns of behaviour began, what function they served in the past, and why they may be continuing
• consider alternative ways of thinking and behaving in the situations that cause difficulties
• try out new and more adaptive ways of behaving and responding to emotions.
The therapist’s role is to respond to the emotional as well as the intellectual content of the patient’s utterances (e.g. ‘It sounds as though you felt angry when this happened’). He helps the patient to examine feelings that previously have been denied, and to think about past situations in which similar feelings were experienced. The therapist pays as much attention to the patient’s non-verbal behaviour as to their words, because discrepancies between the two often point to problems that are not being expressed directly. He maintains the focus—that is, he avoids problem areas which are too complex to deal with in the agreed time.
Interpretations of the patient’s behaviour, thoughts, and feelings are key features of dynamic therapy. These are essentially hypotheses linking present or past events and behaviours. Alternatively they can be observations of defence mechanisms, such as blocks in recall during the sessions, or behaviour that is unconsciously protecting the patient from difficult feelings.
Transference and counter-transference. The therapist is alert to the development of transference and counter-transference (see p. 574). Transference can be a key to how the patient responds to other people at the present time, or how they responded to their parents in childhood. In brief therapy, counter-transference is usually taken to include both appropriate and inappropriate responses by the therapist to the patient’s emotional state. Because insight into counter-transference is difficult to maintain, therapists should regularly consult with a supervisor.
Ending treatment. To ensure that treatment ends on time, realistic goals should be chosen and the focus should remain on these goals. The difficulty, and inevitability, of termination should be discussed from an early stage. As the end of treatment approaches, the patient should feel that they have a better understanding of the chosen problems and should be more confident about dealing with them. It is common to arrange a couple of follow-up appointments spaced over 2 or 3 months.
Because there is only limited evidence from randomized clinical trials, the indications for short-term dynamic psychotherapy have to be based on clinical experience. This suggests that treatment is more useful when the problem:
• can be conceptualized in psychodynamic terms
• is emotional or interpersonal (rather than a specific psychiatric disorder)
• involves low self-esteem, and recurrent problems in forming intimate relationships.
• In addition, treatment is more effective when the patient:
• has adequate social support while treatment continues
• is willing to attempt change through their own efforts
• can look honestly at their own motives
• is capable of ceasing self-exploration when the sessions end.
Contraindications include obsessional or hypochondriacal disorders, severe mood disorder, psychoses, and some personality disorders, especially those characterized by acting out. For a review of the theories and methods of brief individual dynamic psychotherapy, see Hobbs (2005).
Cognitive–analytic therapy was developed by Tony Ryle as a form of brief therapy. Treatment is based on a procedural sequence model that supposes that purposeful behaviour activity follows a sequence consisting of aim generation, evaluation of the environment, planning, action, evaluation of the consequences, and, if necessary, revision. Procedural sequences can be faulty in three ways.
• Traps are repetitive cycles of behaviour in which the consequences of behaviour perpetuate it. For example, depressed people think in ways that lead to failure, making further depression more likely (see p. 586).
• Dilemmas are false choices or unduly narrowed options. For example, people who fear angry feelings may think that the only alternative to aggression is excessive submission. This allows others to take advantage of them, making them even more angry.
• Snags are the anticipation of highly negative consequences of actions such that the action is never carried out and therefore never subjected to a reality check.
The theory of reciprocal roles was developed when cognitive–analytic therapy was applied to borderline personality disorder. Ryle supposed that, starting from childhood, people develop internalized ‘templates’ of social roles. These templates consist of a role for the self, a role for the other person, and a paradigm of the relationship. Examples of such roles include teacher/pupil, bully/victim, and abuser/abused. When one person adopts one of the reciprocal roles, the other person feels under pressure to adopt the other role. Ryle suggested that these ‘templates’ can become abnormal in three ways.
1. The repertoire of different roles is restricted or distorted.
2. Roles cannot be switched easily.
3. Roles are inflexible and cannot be adapted to new situations.
Scaffolding is the provision of just enough support to enable patients to discover their own solutions. It has to be flexible and appropriate to the different needs of each patient.
Outline of the treatment
Following assessment and an explanation of the treatment, the patient is helped to construct a list of problems, moods, and behaviours, and asked to record their occurrence in a daily diary. From the history and the diary, recurrent maladaptive behaviours, role problems, and faulty procedural sequences are identified and formulated, often using diagrams to explain the procedural sequences. For example, a faulty sequence might begin with the idea that one must try to please everyone, leading to giving way to others, and thereby to frustration and feelings of failure and anger. Specific examples of the general procedures are sought in the diaries, and homework is arranged to try out alternative procedures—for example, asserting oneself appropriately. The origins of maladaptive procedures are also considered from a psychodynamic viewpoint. For example, present mal-adaptive behaviour is viewed as arising from behaviour that may have been adaptive when the person was younger.
The formulation is summarized in the form of a letter to the patient. With help from the therapist, the patient tries to become aware of these behaviours, procedural sequences, and role problems, and attempts gradually to change them. From the start, transference and counter-transference problems are anticipated, identified, and discussed. Treatment usually lasts for 16 to 24 sessions. When it ends, the therapist writes another letter to the patient summarizing their progress, prognosis, and future action, and the patient is asked to write to the therapist summarizing their experience. Patients with borderline personality usually need additional help before they can become aware of their problems (‘develop an observing I’). This help is often provided by the modelling of ways in which the maladaptive elements can be evaluated and analysed, often with the aid of diagrams. Object relations (see above) and social interaction concepts are used to understand the genesis of the problems, but defence mechanisms are not viewed as important.
In the absence of high-quality evidence from randomized clinical trials, the use of cognitive–analytic therapy is based mainly on clinical experience. There is some early evidence of its value in young patients and those with borderline personality disorder (Chanen et al., 2008). For further information about cognitive analytic therapy, see Ryle and Kerr (2002).
Long-term individual dynamic psychotherapy
Long-term individual dynamic psychotherapy is a general term referring to many kinds of individual psychotherapy that last for longer than the 9 months that is usually regarded as the upper limit of brief dynamic psychotherapy. The longest, most intensive, and best known form is psychoanalysis, and most methods are derived from it. Long-term dynamic psychotherapy is costly, and because its results have not been shown to be superior to those obtained with shorter forms, it is rarely available in public health services. When used, it is usually reserved for patients who are judged to be too difficult for short-term psychotherapy (even though it is in these cases that its effects are least certain). It is still used as a training experience for psychotherapists.
The primary aim of long-term dynamic psychotherapy is to increase insight. Insight is ‘the conscious recognition of the role of unconscious factors on current experience and behaviour’ (Fonagy and Kächele, 2000), but requires more than an awareness of these factors. It involves the integration of this knowledge into ways of thinking, feeling, and behaving—a process that is called ‘working through.’ Insight is achieved by bringing to conscious awareness mental contents that were previously outside consciousness, by interpreting their significance, and by linking past experiences with present modes of functioning.
Unconscious material is brought to conscious awareness through free association, and by examining the content of fantasies and dreams. Analysis of the patient’s unrealistic responses to the therapist (the transference) provides further information about unconscious processes. Therapists vary in the extent to which they work with the transference. Analysis of the counter-transference provides further relevant information, as it reflects aspects of the patient to which the therapist is responding. The need to understand counter-transference is one reason for engaging in personal psychotherapy during training.
Attempts to access unconscious material and to increase insight activate resistance of three kinds:
1. resistance by repression, which blocks access to unconscious material
2. transference resistance, which restricts the intensity of the relationship with the therapist
3. a negative therapeutic reaction, which is expressed in new symptoms that retard progress.
Although resistance impedes progress, analysis of resistance can increase insight.
Interpretations are generally regarded as one of the main techniques in this kind of treatment. Interpretations may be concerned with defences, unconscious processes, transference, or the links between past experience and present patterns. Transference interpretations are accorded greater importance in long-term therapy.
Long-term psychodynamic psychotherapy also differs from brief dynamic psychotherapy in the following respects:
• It is less structured—the patient is encouraged to talk and associate ideas freely without a specific focus.
• The therapist is less active and guides the patient less. He tries to make the material clearer by asking questions, pointing out contradictions, commenting on evasions and resistance, and making interpretations.
• Patients may be seen twice a week (up to five times a week in classical analysis, although this is vanishingly rare nowadays).
Treatment in groups
This is psychotherapy carried out with a group of usually about eight patients. Small-group psychotherapy is used most often to modify interpersonal problems, as a form of supportive treatment, or to encourage adjustment to the effects of physical or mental illness.
The origins of group psychotherapy
Group therapy originated with the attempts of an American physician, Joseph Pratt, to assist patients with pulmonary tuberculosis (Pratt, 1908). Pratt’s groups were essentially supportive and educational. The main origins of modern group therapy were in the treatment of war neuroses in the 1940s in the UK.
In the Northfield Military Hospital in England, S.H. Foulkes developed group analysis (Foulkes and Lewis, 1944). He based his approach on psychoanalysis so that the group leader took a rather passive role, and used analytical interpretations. W.R. Bion, a Kleinian analyst who also worked there, focused specifically on the unconscious defences of the group as a whole rather than on the problems of individual members (Bion, 1961).
In the USA, in the 1960s and early 1970s so-called ‘action groups’ provided a more intense experience. Group techniques are legion, but what they have in common seems more important than the differences.
Classification of small-group therapies
One classification of groups is by their goals (specific versus non-specific) and the activity of the leader (high versus low) (Pines and Schlapobersky, 2000):
1. Specific goals—high leader activity: includes structured programmes for alcohol and drug dependence, as well as cognitive–behaviour therapy carried out in a group.
2. Specific goals—low leader activity: includes problem-solving groups.
3. Non-specific goals—high leader activity: includes the many kinds of short-term group therapy, as well as psychodrama.
4. Non-specific goals—low leader activity: includes the various kinds of psychodynamic group such as the Tavistock, eclectic, and interpersonal approaches, and group analytical therapy.
Groups are often described in terms of their structure, process, and content.
• Structure describes the enduring reciprocal relationships between each member of the group and the therapist, and between the members.
• Process describes the short-term changes in emotions, behaviours, relationships, and other experiences of the group.
• Content refers to the observable events in the group meetings—the themes, responses, and discussions, and the silences.
Therapeutic factors in group therapy
Group treatments share the therapeutic factors common to all kinds of psychological treatment, namely restoring hope, releasing emotion, giving information, providing a rationale, and prestige suggestion (see Box 20.1). In group treatment there are additional factors which are not present in individual therapies but are common to all kinds of group psychotherapy. These factors are shared experience, support for and from group members, socialization, imitation, and interpersonal learning (Yalom and Leszcz, 2005). These factors are summarized in Box 20.7.
General indications for group therapy
Group or individual therapy?
There is no strong evidence that the results of group therapy differ in general from those of individual psychotherapy of the same duration and used for the same problem. Nor is there evidence that the results of any one form of group therapy differ from those of the rest. However, clinical experience often suggests that group treatments are somewhat less effective than individual therapies unless they draw heavily on shared clinical features.
What problems are suitable?
Group therapy appears to be useful for patients whose problems are mainly in relationships. Patients with moderate social anxiety benefit from the opportunity to rehearse social behaviour. However, severe social anxiety would be a contraindication.
Contraindications for group therapy
These are similar to the contraindications for individual psychotherapy (see above), with the addition of severe social anxiety.
Types of small-group psychotherapy
Many of the therapeutic factors that are present in a group (see Box 20.7) are at work in supportive treatment. In a supportive group, the therapist should encourage self-help and ensure that the experiences of the group members are used positively. He should also ensure that relationships do not become too intense, protect vulnerable patients when necessary, and ensure that each member is supported by and gives support to other members.
Self-help (‘mutual-help’) groups
Self-help groups are organized and led by patients or former patients who have learned ways of overcoming or adjusting to their difficulties. The other group members benefit from this experience, from the opportunity to talk about their own problems and express their feelings, and from mutual support. Group processes develop as strongly in these groups as in any other, so it is important that those who lead them have appropriate training and support. Some groups, such as Alcoholics Anonymous, have strict rules of procedure; others have a professional adviser.
Box 20.7 Therapeutic factors in group therapy
Universality (shared experience). This helps the patient to realize that they are not isolated and that others have similar experiences and problems. Hearing about others’ experiences is often more convincing and helpful than reassurance from a therapist.
Altruism. Supporting others increases the self-esteem of the person giving the support, as well as helping the receiver. Mutual support is one of the factors that lead to a sense of belonging to the group.
Group cohesion. The feeling of belonging to the group is especially valuable for patients who have previously felt isolated. Group cohesion can sustain the group when problems threaten to destroy it.
Socialization. This involves the acquisition of social skills within a group as a result of the comments and reactions of members in response to one another’s behaviour. Members can try out new social behaviours within the safety of the group.
Imitation. This involves learning from observing and adopting the behaviours of other group members. If the group is run well, patients imitate adaptive behaviours. If it is not run well, they may imitate maladaptive behaviours such as extravagant displays of emotion, or talking in a way that deflects attention from their own emotional problems.
Interpersonal learning. This involves learning from the interactions within the group and from practising new ways of interacting. Interpersonal learning is an important component of group therapy.
Recapitulation of the family group. As the group proceeds, interactions become increasingly unrealistic and based on past relationships between patients and their parents and siblings. This group transference eventually develops in all groups. It is encouraged and used in some treatments, mainly those that use a psychoanalytical approach.
There are self-help groups for people who suffer from a wide range of different problems—for example, Alcoholics Anonymous (see p. 461), Weight Watchers, groups for patients with chronic physical conditions such as colostomy, groups for people facing special problems such as parents with a handicapped child, and groups for the bereaved (CRUSE Clubs). Only a few self-help groups (now often referred to as ‘mutual-help groups’) have been evaluated, and they generally demonstrate modest benefits (Pistrang et al., 2008).
Interpersonal group therapy
Interpersonal group therapy developed in particular from the work of Yalom and Leszcz (2005). Treatment is focused on problems in current relationships, and examines the ways in which these problems are reflected in the group. The past is discussed only in so far as it helps to make sense of the present problems.
Preparation for the group
It is useful to prepare patients for their experience in a group by emphasizing the following points.
• Confidentiality: the proceedings of the group are confidential.
• Reliability: members must attend regularly and on time, and not leave early.
• Disclosure: members are required to disclose their problems.
• Concern: members must show concern for the problems of others.
• Disappointment: at first members may be disappointed by the lack of rapid change, or frustrated by the need to share the time available for speaking.
• Keeping apart: The group members should not meet outside the group, and if they do so this should be reported at the next meeting.
• Duration: the length of the group is explained (e.g. ‘10 weeks’ or ‘2 years’), together with the need to remain until the end.
Setting up the group
General considerations. About eight members are chosen. They should have some problems in common, and no member should have exclusive problems that set them apart from the rest. Meetings should be held in a room of adequate size, with the chairs arranged in a circle so that all members can see one another.
Meetings usually last for 60 to 90 minutes to allow adequate time for every member to take part; they are usually held once a week, and generally continue for 12 to 18 months. Most groups are ‘slow open’, with new members joining only to replace those who leave. Totally closed groups are very difficult to maintain, and are rarely offered except in residential settings. Groups that accept new members frequently, known as open groups, are usually supportive or psycho-educational.
One or two therapists? Most groups are run by one therapist, but many have co-therapists. The advantage of having two therapists is both practical and theoretical. It ensures continuity if one of the therapists has to be away, and it also provides an excellent training opportunity. Theoretically it can also help with counter-transference problems. The risk is that co-therapists may compete with or behave defensively towards one another. However, in general if differences are discussed as they arise, they can provide further insight into the group process and offer some healthy modelling of problem exploration and resolution.
Some problems in group therapy
However skilful the therapist, certain problems commonly arise in the course of group therapy.
• Formation of subgroups. Some members may form a coalition based on age, social class, shared values, or other characteristics. The therapist should discourage such groupings by asking the group to discuss the reasons for their formation.
• Members who talk too much. The therapist should draw attention to this problem at an early stage, before the group rejects the talkative member. He can do so by asking the group why they allow one person to absolve the rest from the need to speak about themselves.
• Members who talk too little. The therapist should assist silent members to speak and should therefore understand the reasons for silence.
• Conflict between members. The therapist should not take sides in conflicts but should encourage the whole group to discuss the issue in a way that leads them to understand why the conflict has arisen—for example, because a hostile transference has developed.
• Avoidance of the present. Sometimes group members talk excessively about the past as a way of avoiding present conflicts. When this happens, the therapist can ask questions or use interpretations as an indirect way of bringing the discussion back to the present problems, or by actively relating the issue to the current group process.
• Potentially embarrassing revelations. Common sense and judgement have to be used to protect vulnerable patients from blurting out potentially devastating information (e.g. about sexual or even criminal activity) before they are well established in the group.
This technique, which was pioneered by Foulkes (see above), has been widely used within the UK health service. It differs from the interpersonal method described above, first in the greater use of interpretations about transference and unconscious mechanisms, and secondly in the use of ‘free-floating discussion’ instead of a focus. Particular attention is given to transferences to the therapist and between members. The resulting hypotheses about previous relationships are used to understand current problems.
Encounter groups and psychodrama (action techniques)
In encounter groups the interaction between members is actively intensified to stimulate greater change. The encounter can be entirely verbal, using challenging language, or it can include touching or hugging between the participants. Sometimes the group sessions last a whole day or even longer (marathon groups). These groups are attractive to volatile individuals and do carry some risks of things getting worse. Psychodrama groups enact events from the life of one member, in scenes reflecting either current relationships or those of the family in which the person grew up. The enactment usually provokes strong feelings in the person represented, and often reflects the problems experienced by other members of the group. Members sometimes exchange roles so as to understand better the other person’s point of view. The drama is followed by a group discussion. Psychodrama is found useful with less educated and verbal patients, and is favoured in some prison settings.
Group meetings, often called ‘community meetings’, are part of the daily programme of many psychiatric wards. The approach originated in therapeutic communities. These are large groups, usually including all of the patients in a treatment unit together with some or all of the staff. At the simplest level, large groups allow patients to examine and deal with the problems of living together. They can confront individual patients about disordered or disruptive behaviour, and provide opportunities for social learning. Care needs to be exercised, and a predominantly supportive atmosphere is needed for this approach to work. The group is sometimes used as a kind of governing body that formulates rules and seeks to enforce them.
In a therapeutic community, every shared activity is viewed as a potential source of learning and change. Members live, work, and play together and learn about themselves through the reactions of other members in the course of these activities. Within the safe environment of the community, they are encouraged to experiment with new behaviours and appreciate points of view other than their own. Members take part in frequent group meetings. Maxwell Jones, one of the founders of this form of treatment, referred to it as a living-learning situation (Jones, 1968); others have called it a culture of enquiry. Originally there were usually 20 to 30 members of the community who stayed for between 9 and 18 months. The underlying principles of the regimen have been summarized as democracy, reality confrontation, permissiveness, and communality (Rapoport, 1960). These translate into the features shown in Box 20.8. Residential therapeutic communities are no longer available in the NHS. The approach is predominantly applied in day units and in drug rehabilitation and some offender institutions.
Therapeutic day hospitals
Therapeutic day units have been developed for the treatment of personality disorder (Bateman and Fonagy, 2008), and are now increasingly widespread. They basically have a similar structure to therapeutic communities, with a culture of enquiry, but they emphasize ‘mentalization.’ They are informed by psychoanalytical theory, but emphasize group work and a supportive environment. Using nurse therapists, the aim is to help patients to become aware of their emotions and learn to tolerate them, rather than act them out. There is not such a strong emphasis on linking back to past experience as long as the patient can begin to manage their intense emotions.
Box 20.8 Principal features of a therapeutic community
Informality. There are few rules, and staff dress and behave informally.
Mutual help. Members support each other and help others to change.
Permissiveness. Members tolerate behaviour that they might not accept elsewhere.
Directness and honesty. Members respond directly to distortions of reality and other kinds of self-deception.
Shared decisions. Members and staff join in the day-to-day decisions about the running of the unit, the behaviour of its members, and usually about the admission of new candidates.
Shared activities. Members provide some of the ‘hotel’ services in the community, so that each has a job involving responsibilities to other people.
Psychotherapy with couples and families
Couple therapy is usually proposed either because conflict in a relationship appears to be the cause of emotional disorder in one of the partners, or because the relationship is unsatisfactory or likely to break up, and both partners wish to save it. The problem is conceived as resulting from the way in which the couple interact, and treatment is directed to this interaction. To avoid imposing values, the therapist adopts a ‘target problem’ approach, whereby couples are required themselves to identify the difficulties that they would like to put right.
Several techniques of therapy have developed, based on psychodynamic, behavioural, and systems theory approaches, and on a combination of techniques drawn from the latter two approaches.
Several, sometimes all, members of a family take part in this treatment. Usually both parents are involved, often together with the child whose problems have led the family to seek help. They may be joined by other members of the extended family. The aim of treatment is to improve family functioning, and so to help the identified patient. Since success depends on the collaboration of several people, dropout rates are high. Whatever their method, family therapists have the following goals for the family:
• improved communication
• improved autonomy for each member
• improved agreement about roles
• reduced conflict
• reduced distress in the member who is the patient.
The systems approach is very influential, and was developed in the USA by Salvador Minuchin, who advocated a practical approach to resolving problems in his structural family therapy. In Italy, the Milan school used hypotheses about the family system to suggest ways of promoting change. These approaches are described briefly below, together with an eclectic approach. The reader will find more detailed accounts in the chapter by Bloch and Harari (2005). Family therapy is used in the treatment of some young people with anorexia nervosa after weight has been restored by other means (see p. 356). Special kinds of family treatment have been developed to reduce relapses in schizophrenia (see p. 289).
Systemic family therapy
Systemic family therapy is concerned with the present functioning of the family, rather than with members’ past experiences. The therapist’s task is to identify the family’s unspoken rules, their disagreements about who makes these rules, and their distorted ways of communicating. The therapist helps the family to understand and modify the rules, and to improve communication.
The Milan approach (Palazzoli et al., 1978) usually consists of 5–10 sessions, spaced at intervals of 1 month or more (‘long brief therapy’). Circular questioning is often used to assess the family. In this technique, one person is asked to comment on the relationships of others—for example, the mother may be asked how her husband relates to their son, and others are asked to comment on her response. The purpose is to discover and clarify confused or conflicting views. A hypothesis is then constructed about the family functioning and presented to the family, who are asked to consider the hypothesis during and between sessions. The family may be asked to try to behave in new ways. Sometimes the therapist provokes change with paradoxical injunctions designed to provoke the family into making changes that they cannot make in other ways. Paradoxical injunctions are impossible or counter-intuitive suggestions that force the family to confront their hidden or unacceptable motives. A review of 10 outcome studies of Milan therapy found symptomatic improvement in about two-thirds of patients, and improved functioning in about 50% of the families (Carr, 1991).
Eclectic family therapy
In everyday clinical work, especially with adolescents, it is almost impossible to do without simple short-term interventions to bring about limited changes in the family. The present situation of the family and how the members communicate with one another is usually the focus.
Assessment of family structure summarized as a geno-gram using conventional symbols (see Figure 20.1) is a particularly useful step in family therapy. Further questions concern the current and past state of family life, and the roles of the members. The therapist tries to answer two questions, namely how the family functions, and whether family factors are involved in the patient’s problems. Bloch and Harari (2005) have proposed a useful framework in which to consider these questions.
Figure 20.1 Symbols used in the construction of a genogram. From Crowe, M. (2000). Psychotherapy with couples. In MG Gelder, Andreasen NC, López-Ibor JJ Jr, and Geddes JR (eds). The new Oxford textbook of psychiatry, Chapter 6.3.7. Oxford University Press, Oxford.
1. How does the family function?
• structure recorded in the genogram (e.g. single parent, a step-parent, size and age spread of the sibship)
• changes and events (e.g. births, deaths, departures, and financial problems)
• relationships (e.g. close, distant, lsoving, conflictual, etc.)
• patterns of interaction involving two or more people (e.g. a child who sides with one parent against the other).
2. Are family factors involved in the patient’s problems? The family may be:
• reacting to the patient’s problems (note that there may be other, unrelated problems)
• supporting the patient
• contributing to the patient’s problems (e.g. the problems of a daughter who cannot leave her lonely mother).
Specific goals for change are agreed with the members of the family, who are asked to consider how any changes will affect themselves and others, and what has prevented the family from making the changes. Paradoxical injunctions may be included, but should be made only after the most careful consideration of the range of possible responses. The therapist should remember that interchanges in the sessions are likely to continue when the family return home, and should try to ensure that this does not lead to further problems.
Results of family therapy
In a meta-analysis of the results of 19 studies of family therapy, the effect was found to be comparable to that obtained with other forms of psychotherapy. About 75% of patients receiving family therapy had a better outcome than similar patients receiving minimal or no treatment (Markus et al., 1990). For children and adolescents, family therapy appears to be an effective treatment for eating disorders, substance abuse, and conduct disorder, although the patients treated were not necessarily representative of the groups as a whole (Cottrell and Boston, 2002).
Psychotherapy for children
The kinds of psychotherapy discussed so far do not lend themselves to the treatment of young children who lack the necessary verbal skills. In practice there are fewer difficulties than might be expected, because many emotional problems of younger children are secondary to those of their parents, and it is often appropriate to direct psychotherapy mainly to the parents.
Some psychotherapists (most notably Melanie Klein) believe that it is possible to use the child’s play as equivalent to the words of the adult in psychotherapy. Anna Freud developed child psychotherapy by a less extreme adaptation of her father’s techniques to the needs of the child. She accepted that non-analytical techniques could be helpful, including reassurance, suggestion, the giving of advice, and acting as a role model (an ‘auxiliary ego’). However, for neurotic disorders in childhood, and for the many mixed disorders, she advocated analytical techniques to identify the unconscious content of the disorder and to interpret it in a way that strengthens ego functions.
In the UK, most psychotherapy for children is eclectic; the therapist tries to establish a good relationship with the child and to learn about their feelings and thoughts, partly through talking and listening, and partly through play. Older children can communicate verbally with adults, but younger children can communicate better through actions, including play. The therapist can help children to find words that express their thoughts and feelings, and can thus make it easier for them to control and change these thoughts and feelings. However, it is important to ensure that the therapist’s interpretations do reflect the child’s own thoughts and are not implanting new ideas. Child psychotherapy is discussed further in Chapter 22 (see p. 641). For a more detailed account, see Target et al. (2005).
Psychotherapy for older people
Increasing emphasis is being placed on the provision of psychological treatments as part of the care plan for elderly patients. Provided that they do not have cognitive impairment, elderly patients can take part in any of the treatments described for younger adults. When using cognitive therapy, it is important to search for minor degrees of cognitive impairment that are insufficient to affect general functioning but enough to impair the patient’s grasp and retention of the details of the therapy. For a review of psychotherapy for the elderly, see Garner (2003), and for a more detailed account see Cook et al. (2005).
Treatments of mainly historical and cultural interest
In our evidence-based era it may seem inappropriate to list treatments that have fallen into disuse because of lack of effect. However, many of these treatments have entered our culture and have a strong hold on the public imagination. Psychiatrists are likely to be approached by patients who are keen to receive such treatments, and we need to be familiar with them in the same way as we are with outdated but influential concepts such as the schizophrenogenic mother.
Hypnosis is a state in which the person is relaxed and drowsy, and more suggestible than usual. Hypnosis can be induced in many ways. The main requirements are that the subject should be willing to be hypnotized and convinced that hypnosis will occur. Most hypnotic procedures contain some combination of a task to focus attention (e.g. watching a moving object), rhythmic monotonous instructions, and the use of a graduated series of suggestions (e.g. that the person’s arm will rise). The therapist uses the suggestible state either to implant direct suggestions of improvement, or to encourage recall of previously repressed memories.
Hypnosis is used infrequently in psychiatry. A light trance is used occasionally as a form of relaxation. For this purpose hypnosis has not been shown to be generally superior to relaxation. A deeper trance is used occasionally to enhance suggestion in order to relieve symptoms, especially those of conversion disorder. Although sometimes effective in the short term, this method has not been shown to be superior to suggestion without hypnosis. The authors do not recommend the use of hypnosis in clinical psychiatry.
Autogenic training was described by Schultz in 1905 and was in use mainly in continental Europe as a treatment for physical symptoms caused by emotional disorder (Schultz, 1932). Patients practise exercises to induce feelings of heaviness, warmth, or cooling in various parts of the body, and to slow their respiration. Repeated use of these exercises is supposed to induce changes in autonomic nervous activity, thereby alleviating physical symptoms in stress-related and anxiety disorders, including hypertension. Its results do not differ substantially from those achieved with simple relaxation, nor is there any good evidence that it has a specific therapeutic effect.
Abreaction (the unrestrained expression of emotion) has long been used to relieve mental distress and some psychiatric symptoms. Abreaction is part of many forms of religious healing (see below). It was used to great acclaim during the Second World War, using rapid-acting barbiturates to bring prompt relief from acute war neuroses (predominantly acute stress disorders), notably by Sargant and Slater (1940). In civilian practice, abreaction is less effective, perhaps because fewer disorders are the result of overwhelming stress. For more information about the latter procedure, see Sargant and Slater (1963).
Meditation and yoga are increasingly used by people with minor psychiatric problems as an alternative or adjunct to psychiatric treatment. There are many approaches, each associated with a different system of belief, but sharing common features. They involve relaxation and the regulation of breathing, and directing attention away from the external world and from the stream of thoughts that would otherwise occupy the mind, often by repeating a word or phrase (a mantra). An important feature is setting time aside when calm can be restored. In addition, the espousal of a value system and association with similar-minded individuals (the activities are commonly group based) may explain some of the reported successes of the methods. Aspects of meditation have been incorporated into MBCT (see p. 243).
Traditional healing still plays an important part in many individuals’ lives, and is often a precursor to seeking professional help. It is not restricted, as is often assumed, to ethnic-minority groups. Alternative medicines and treatments are ubiquitous in all strata of society. However, the use of traditional healers is generally restricted to minority groups. Traditional healers can be broadly divided into four groups (Jilek, 2000).
• Herbalists are concerned mainly with plant remedies, some of which are known to contain active ingredients, while others appear to be placebos.
• Medicine men and women use verbal or ritual methods of healing, sometimes combined with plant remedies. They are believed to have special powers, often of supernatural origin.
• Shamans use methods like those of medicine men and women, but also enter into altered states of consciousness in which they are believed to communicate with spirits or ancestors, and to recover the abducted souls of people made ill by this supposed loss.
• Diviners discover and name the cause of illness by interpreting oracles (in either clear or altered consciousness), from the content of dreams, or through some form of communication with ancestors or spirits.
Traditional healers use methods that incorporate the non-specific processes in Western psychological treatment (see Box 20.1). In addition, they are aware of the value of naming a condition and answering the questions ‘Why am I afflicted?’ and ‘Why is this member of our family afflicted?’, thus ending uncertainty and relieving feelings of blame and guilt. Some traditional healers use therapeutic suggestion, and many involve the family both in the diagnostic process and in the rituals of treatment. Some employ cleansing or purification rituals to eliminate supposed polluting agents. A few healers use sacrificial rites to appease supernatural beings, sometimes combining these with confession and a promise of changed behaviour. They may involve the wider community as well as the patient and the family. Traditional healing is not necessarily incompatible with modern medicine, and may be running parallel with it more often than we ascertain.
Ethical problems in psychological treatment
The need for informed consent is as great in psychological treatment as in any other treatment, and to give such consent the patient must understand the nature of the treatment and its likely consequences. Such preparation is not only ethically desirable but also likely to improve the therapeutic alliance.
Group psychotherapy presents special problems of confidentiality. Patients should understand fully the requirement to talk of personal matters in the group, but they need to understand equally clearly the requirement to treat as confidential the revelations of other patients. Family therapy presents similar problems, especially if the therapist agrees to see one member outside the family session, and is told of a family secret (e.g. relating to an extramarital affair). Wherever possible the therapist should avoid such individual meetings and arrange for a colleague to see the family member if this is necessary (e.g. if one member is seriously depressed). Similar problems arise in couple therapy.
The answer to the question of when a therapist should reveal confidential material to a third party is the same as in other treatment situations, namely that it is justified when there is a substantial risk to a third party. Confidentiality is often confused with secrecy in psychotherapy (both by patients and by some therapists). Modern mental healthcare utilizes a model of shared responsibility, and often information must be shared. Only in exceptional cases should patients be promised that ‘absolutely no one else will know of this.’
Patients who are receiving psychological treatment are particularly vulnerable to exploitation. This arises from the experiences that cause them to seek psychotherapy, but also because of the intense and often dependent relationship with the therapist. As in other branches of medicine, exploitation may be financial or sexual. Financial exploitation is a potential problem in private practice, in which treatment may be prolonged for longer than is necessary. Occasionally the exploitation is sexual. In the medical and other caring professions, such exploitation is prohibited in professional codes of conduct. Several rogue therapists have defended inappropriate sexual contact as ‘therapeutic’ and, remarkably, in some cases have succeeded in this defence. However, it is never acceptable to form a sexual relationship with a current or previous patient. In some jurisdictions (e.g. some US states) there are evolving guidelines about the time that must elapse before such relationships can be considered acceptable.
Another form of exploitation is the imposition of the therapist’s values on the patient. This may be open and direct (e.g. when a therapist imposes his view that termination of pregnancy is morally wrong) or it may be concealed and indirect (e.g. when a therapist expresses no opinion, but nevertheless gives more attention to the arguments against termination than to those for it). Similar problems may arise, for example, in couple therapy when the therapist’s values may affect his approach to the question of whether the couple should separate. A controversial issue is that of ‘implanting’ erroneous explanations. This has become very contested in relation to ‘recovered memory’ syndrome, where the recall, after many years, of early familial sexual abuse has been attributed to therapists exploiting suggestibility. Although there has been no suggestion that this is deliberate, there is considerable professional doubt about its status, and the consequences are so potentially catastrophic that it requires very careful monitoring.
In group psychotherapy, one patient may be exploited by another. This is one of the reasons for proscribing contact outside the group. One patient may bully or scapegoat another within the sessions of treatment, or may seek a sexual relationship. The therapist should try to protect vulnerable patients within the sessions. Clearly it is not possible to be as strict in this matter as in a professional relationship, but strongly emphasizing the purpose of the therapy rules is key to minimizing the problem.
Bloch S (2005). An Introduction to the Psychotherapies, 4th edn. Oxford University Press, Oxford. (An introduction to the commonly used psychological treatments, with a chapter on ethics.)
Bateman A, Brown D and Pedder J (2000). Introduction to Psychotherapy: an outline of psycho-dynamic principles and practice, 3rd edn. Tavistock/Routledge, London. (An account of dynamic theory, and practice in individual, couple, family, and group formats.)
Frank JD and Frank JB (1993). Persuasion and Healing, 3rd edn. Johns Hopkins Press, Baltimore, MD. (A revised version of a landmark account of the non-specific factors in psychotherapy.)
Gabbard G, Beck JS and Holmes J (2005). Oxford Textbook of Psychotherapy. Oxford University Press, Oxford. (A comprehensive set of reviews of the major forms of psychotherapy and their use in clinical practice.)
Gurman AS (ed.) (2003). Family Therapy: theory, practice and research. Brunner-Routledge, London. (A comprehensive work of reference.)
Hawton K, Salkovskis PM, Kirk JW and Clark DM (2000). Cognitive Behavioural Approaches for Adult Psychiatric Disorders: a practical guide, 2nd edn. Oxford University Press, Oxford. (An introduction with many valuable practical examples.)