Psychological treatments

Psychological treatments may be used alone or in combination with physical treatments. They provide some of the most powerful means of treating many types of mental illness. The three main types of psychological treatment are dynamic psychotherapy, behavioural psychotherapy and cognitive psychotherapy. There is much debate about the relative merits of these and, as will be seen in this section, all appear to have a role. In deciding which psychotherapy, if any, to recommend to patients, it is important to consider the nature of their problems, as well as how receptive they are likely to be to the different approaches.

Behavioural psychotherapy

The term behavioural psychotherapy covers a range of treatments, all of which make unwanted behaviours the focus of treatment. They include relatively simple techniques such as relaxation training, in which participants learn to reduce the somatic symptoms of anxiety through controlled breathing and muscle relaxation. Most other behavioural techniques are based on the psychological theory of operant conditioning which states that a behaviour is reinforced (i.e. is more likely to be repeated) if it has positive consequences. Positive reinforcement is when a behaviour increases because something good happens as a result, whereas with negative reinforcement a behaviour increases because it causes something unpleasant to go away. It will be seen from this description that negative reinforcement is not the same as punishment. When operant conditioning is involved in the development of mental illness, it is usually through negative conditioning. For instance, avoidance of going outside in agoraphobia or carrying out compulsions in obsessive–compulsive disorder are associated with a reduction in levels of anxiety and so these behaviours increase in frequency. Similarly, during depressive episodes, routine activities can lead to increased fatigue and feelings of failure if the patient finds them difficult to complete. In such cases, activity levels decrease because of negative reinforcement.

Operant conditioning is also important during treatment. For instance, in exposure therapy for agoraphobia, the therapist will explain to the patient that, if they force themselves to endure the anxiety associated with going out, it will eventually subside. When the patient discovers this to be true, negative reinforcement occurs, and they become less likely to give in to the anxiety next time it occurs. Common ways in which operant conditioning is applied to clinical situations are shown in Table 1.

Table 1 Use of operant conditioning in behaviour therapy

Technique	Indications	Process
Exposure therapy	Simple phobia, agoraphobia	Identify things or places which lead to anxiety
		List these in order, i.e. a hierarchy with most anxiety-provoking situations at the top
		Expose patient to situation at bottom of hierarchy until no longer causes anxiety
		Move on to next situation in hierarchy
Response prevention	Obsessive–compulsive disorder	Gradually reduce the number of times the person carries out the unwanted act, e.g. for compulsive handwashing, make the patient repeatedly ‘contaminate’ their hands and gradually reduce the time they spend washing them afterwards
Behavioural activation	Depressive disorder	Patient avoids doing things as they think they will not enjoy them or will feel a failure if they do not complete them
		Make realistic and achievable plans to carry out activity each day
		Gradually increase the amount of activity

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