Psychological treatments
How psychological treatments developed
Classification of psychological treatments
Common factors in psychological treatment
Counselling and crisis intervention
Individual dynamic psychotherapies
Psychotherapy with couples and families
Psychotherapy for older people
Treatments of mainly historical and cultural interest
Ethical problems in psychological treatment
Introduction
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-Freudians
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:
• Eclectic
• Psychodynamic
• Cognitive–behavioural
• 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.
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
Counselling
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
Debriefing
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
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
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
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
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 |
Encourage hope |
Review and develop assets |
Encourage self-help |
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
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).
Cognitive–behaviour therapy
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.
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 20.3 contains 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.
Table 20.3 Topics to be considered during assessment for cognitive–behaviour therapy
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 formulation
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.
Behavioural techniques
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.
Relaxation training
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
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.
Desensitization
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.
Flooding
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
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.
Anger management
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’).
Self-control techniques
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
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).
Enuresis alarms
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
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.
Cognitive techniques
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.
Cognitive–behavioural treatments
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).
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