Current Psychological Approaches In The Management of Mental Health Problems

1. Current Psychological Approaches In The Management of Mental Health Problems Toyin Idowu Cognitive Behaviour Therapist RN; RMN; BA (Hons) MSc

2. Overview • Understanding Mental Health Problems • Psychopathology of Mental Health Problems • Psychological Perspectives • Evidence-base psychological treatments

3. Mental Health Problems • Daily worries we all experience • To serious long-term conditions • Recovery depend on intervention • Diagnosis Vs Stigma • Quality of life

4. Mental Health Problems • Diagnosis symptoms • Differences across cultures • In definition and classification • Standard Criteria Guidelines

5. Mental Health Problems One third of people at some point in their life reported symptoms which meet criteria for diagnosis of one or more of the common types of mental disorder WHO (2004)

6. Classification • Key Issue for researchers and service providers • Determines diagnosis of symptoms • By disorders • Normal vs Abnormal Behaviours • Continuum vs Spectrum Approach • Scientific Vs Subjective Value Judgement

7. The function of classification • Inform effective treatment selection • Administrative functions e.g. Medical aids, legal system. • Provides vocabulary for professionals to communicate. Clinical shorthand. • Provides information on prognosis.

8. Traditional Classifications • Organic/Functional • Neurosis/Psychosis • Minor/Major • Severe Mental Illness • Modern Classifications

9. DSM-IV-TR Larger no. of discrete categories. Uses a multi-axial system. Uses term psychotic. ICD-10 More general categories. Generally single axis. But uses broad aetiology. Uses term neurotic. DSM-IV-TR & ICD-10

10. Psychopathology • Commonly used in Psychiatry • Behaviours or experiences indicative of mental illness • Disease Process • Abnormality in responses of cognition, emotion, physiology and behaviour • Subsequent effect on functioning

11. Classifying PsychopathologyDSM – IV – TR Axis I: Clinical Syndromes • This is what we typically think of as the diagnosis (e.g., depression, schizophrenia, social phobia) Axis II: Developmental Disorders and Personality Disorders • Developmental disorders include autism and mental retardation, disorders which are typically first evident in childhood  • Personality disorders are clinical syndromes which have a more long lasting symptoms and encompass the individual's way of interacting with the world.  They include Paranoid, Antisocial, and Borderline Personality Disorders.

12. Axis III: Physical Conditions which play a role in the development, continuance, or exacerbation of Axis I and II Disorders Physical conditions such as brain injury or HIV/AIDS that can result in symptoms of mental illness are included here.  Axis IV: Severity of Psychosocial Stressors Events in a persons life, such as death of a loved one, starting a new job, college, unemployment, and even marriage can impact the disorders listed in Axis I and II.  These events are both listed and rated for this axis. Axis V: Highest Level of Functioning On the final axis, the clinician rates the person's level of functioning both at the present time and the highest level within the previous year.  This helps the clinician understand how the above four axes are affecting the person and what type of changes could be expected.

13. Example of Diagnosis: • Patient: John Doe • Axis I: Major depressive Disorder • Axis II: Narcissistic Personality Disorder – some features only • Axis III: Poor liver functioning, frequent migraines. • Axis IV: Recently retrenched • Axis V: 65

14. Psychological Perspectives Before Psychology there were Philosophers - asked questions about the mind: • Plato (427-347 BC): Does perception accurately reflect reality? • Aristotle (384-322 BC): Logic forms the laws of thought • Descartes (1596-1650): “I think therefore I am”

15. The Beginning of PsychologyWilhelm Wundt (1832-1920) • Focuses on the scientific study of the mind. • First Experimental Psychological Lab in 1879 • Scientific Method: • Predict what will happen • Systematically observe events • Do events support predictions

16. William James (1842-1910) • Philosopher and Psychologist • Focus on understanding mental Processes • Theory of Emotion • Interpretation of stimulus

17. Ivan Pavlov (1849 – 1936) • Classical Conditioning • Stimulus Response Psychology • "Pavlov's dog" -Someone who merely • reacts to a situation rather than • using critical thinking

18. John Watson (1878-1958) • Theory of Behaviourism • Understanding animal behaviour • Little Albert Experiment • (Unconditioned Stimulus)

19. Sigmund Freud (1856-1939) • The idea of the UNCONSCIOUS • Thoughts, memories & desires exist below conscious awareness and exert an influence on our behavior • Psychoanalytic Theory attempts to explain personality, mental disorders & motivation in terms of unconscious determinants of behavior

20. Contemporary Psychological Perspectives Several theories within an approach Share common assumption. No right or wrong approach Each perspective has its strengths and weaknesses 5 Perspectives

21. Behaviourist Perspectives • People are controlled by their environment • How environmental factors (stimuli) affect observable behaviour (response) • Classical conditioning - Learning by association • Operant conditioning - Learning from the consequences of behaviour (B.R Skinner)

22. Psychodynamic Perspective •  Events in our childhood can have a significant impact on our behaviour as adults (Frued) • People have little free will to make choices in life. • Behaviour is determined by the unconscious mind and childhood experiences. • Id ego and super ego principle

23. Humanistic Perspective • Look at human behaviour from the eyes of the person doing the behaviour • The study of the WHOLE person • individual's behaviour connected to inner feelings and self-image. • Uniqueness of the individual • Individual has free will to change at any time.

24. Cognitive Perspective • Cognition - the mental act or process by which knowledge is acquired. • Mental Processing/Function – memory, perception and attention etc • Human brains as computers • Memory stages (encoding, memory and retrieval) • Basis for cognitive therapy

25. Biological Perspectives • Genetics and evolution play a role in human behaviour – Charles Darwin (1859) • Most behaviours are inherited (Adaptive function) • Brain physiology and behaviour • Abnormal Behaviour • Dopamine and schizophrenia

26. Evidence Base Treatments • Based on Empirical outcome • Science on its own • Eliminates risky practice • Favour better outcomes • Decision Making • Professional practice • Influence outcome • Recovery

27. Types of Evidences (Muir-Gray, 1997) • Type 1 Strong evidence from at least one systemic review of multiple well designed randomized control trials. • Type 2 Strong evidence from at least one properly designed randomized controlled trials of appropriate size • Type 3 Evidence from well designed trials without randomization, single group pre-post, cohort, time series or matched case-control studies.

28. Types of Evidences (Muir-Gray, 1997) • Type 4 Evidence from well designed non-experimental studies from more than one centre or research group. • Type 5 Opinions of well respected authorities, based upon clinical evidence, descriptive studies or reports of expert committees.

29. Evidence Base Psychological Approaches • Practitioners to follow approaches based on the best available research evidence (Sackett et al 2000) • A psychological therapy is efficacious and specific - evidence from at least two settings that it is superior to a pill or psychological placebo or another bona fide treatment (Chambless and Hollon, 1998)

30. Evidence Base Psychological Approaches • EBT not followed rigorously • Not all mental health practitioners trained • Patients are often unaware that evidence-based practices exist. • Consequently, patients do not always receive the most effective, safe, and cost effective treatments available. Berke et al, 2011

31. NICE Guidelines (UK) CBT – Strongest Evidence across mental health problems Dialectical Behaviour Therapy IPT – Depression Behaviour Couples Therapy - depression Counselling - Depression Brief Dynamic Therapy - Depression

32. Psychodynamic Psychotherapy • Focus on revealing the unconscious content of a client's psyche in an effort to alleviate psychic tension • Internal conflicts and their relation to development • Patients develop defences to avoid unpleasant consequences of conflict • Psychopathology develops especially from early childhood experiences • Causing inter-relational difficulties

33. Psychodynamic Psychotherapy • Emerges in Transference and Counter-Transference in therapy • No structure in therapy • Interpreting the dynamics in therapy to work through the presenting symptoms • Ability to trust own insight is critical to successful outcome

34. Counselling • Person Cantered opportunity to vent feelings and emotions • Evaluate own situations and behaviours • Work in a problem solving approach manner

35. Behaviour Couples Therapy • Joint Relationship Treatment • Changing views (Blame-Game) • Modifies Dysfunctional Behaviours • Decrease Emotional Avoidance • Improve Communication

36. Interpersonal Psychotherapy (IPT) • Focuses on the interpersonal context • Building interpersonal skills • Interpersonal factors contribute to psychological problems • Interpersonal not Intra-psychic • Change in behaviour through adaptation to current roles and situations

37. What is CBT ? Mental health problem involves on-going interactions amongst Biological factors genes; biological state Psychological factors cognitions; affects; overt behaviours Social factorsimmediate social environment & culture Mental Health

38. What is CBT ? CBT addresses Psychological aspect of mental health issues Based on idea that thoughts create moods, influence behaviour &alter physiological state Feelings & behaviour depend on interpretation of events

39. What is CBT ? In CBT we help clients learn that we all have inherent tendencies to certain cognitive styles that can evoke mood and behaviour disturbance We can learn to spot unhelpful cognitions as they come up; then challenge and re- think them

40. Cognitive Behaviour Therapy (CBT) • Cognitive Therapy is combined with behaviour ‘experiments’ • These help clients act on their new ideas. Disconfirm original idea and confirm alternative beliefs e.g. asserting self usually does not end in hostility but engenders respect • Reduce behavioral excesses (e.g. avoidance) & deficits (e.g. problem-solving) • When combined, termed Cognitive Behaviour Therapy

41. First Generation CBT Skinner Pavlov Watson BEHAVIOUR THERAPY

42. Second Generation CBT • Beck • Ellis • Social psychology and developing cognitive Sciences • Cognitive therapies

43. Depression Aaron Beck Christopher Martell

44. Generalised Anxiety Disorder Tom Borkovec Michel Dugas

45. Obsessive Compulsive Disorder Steketee/Kozac/Foa Protocol

46. Panic Disorder • Clark • Barlow

47. PTSD • Ehlers • Foa and Rothbaum

48. Psychosis • Garety et al 2001 • Morisson 2001

49. New Wave CBT • Acceptance and Committed Therapy (ACT) – Steven Hayes Chronic Pain; Depression • Dialectical Behaviour Therapy • Mindfulness Based Cognitive Therapy (MBCT) Mark Williams et al Recurrent Depression • Compassion Focussed Therapy (CFT) – Paul Gilbert Shame and Self attack in PTSD

50. Mastery