Overview
The lecture contrasts pharmacological and psychological treatment for mental disorders, then focuses on Cognitive Behavioural Therapy (CBT): what it is, the cognitive-behavioural model of how thoughts, feelings and behaviour maintain a problem, and the four core CBT techniques used to break that cycle (graded exposure, exposure and response prevention, behavioural experiments, and evidence for/evidence against), each illustrated with an example of the kind the exam may ask students to apply to a case.
Treatment options
- Three broad options: medication (pharmacotherapy), psychological treatment (psychotherapy), or a combination of both.
- Guideline comparison tables for Major Depressive Disorder and for anxiety disorders were shown, but the slides state these are not required exam knowledge. General pattern: mild presentations favour psychotherapy alone; moderate-severe presentations shift towards pharmacotherapy or combined treatment, with some variation between guidelines (e.g. CANMAT recommends pharmacotherapy rather than psychotherapy for moderate depression).
- For anxiety disorders (GAD, panic disorder, OCD, PTSD): mild anxiety favours psychotherapy; moderate-severe anxiety favours psychotherapy, or medication if preferred, or medication if psychotherapy is declined, long-standing, or of no benefit.
What is psychotherapy
- Psychotherapy is treatment of mental disorder by psychological, rather than pharmacological, means; a “talking” therapy based on interaction.
- Delivered by trained, qualified professionals: psychiatrists, psychotherapists, registered psychologists, clinical psychologists, counsellors, family therapists, social workers.
- Many forms exist, e.g. psychodynamic, interpersonal, systemic, behavioural, mindfulness, person-centred, cognitive-behavioural.
- Two defining features:
- A relationship between a trained health professional and a person needing help with psychological distress and/or impaired functioning.
- Planned, systematic application of specific psychological principles.
Modes of treatment
Four modes: individual, couple/marital, family, group.
Cognitive Behavioural Therapy (CBT)
- Widely used, evidence-based treatment method.
- Treatment of choice for anxiety disorders (including PTSD and OCD).
- Equal effectiveness to medication for mild-moderate depressive disorders.
- Treatment of choice for alcohol/drug disorders when combined with motivational interviewing (post-detox).
- Treatment of choice for eating disorders, especially bulimia.
- Definition: a short-term psychological treatment for mental disorders that focuses on the links between a person’s thoughts, emotions and behaviour, and the way those links give rise to, or maintain, the disorder.
- Typically time-limited (e.g. 8-15 sessions) and highly structured: begins with assessment and formulation of the problem, then targets the key cycles of thought, behaviour or feeling that maintain the problem or make it worse.
The cognitive-behavioural model
- Core triangle: thought, emotion and behaviour reciprocally influence each other. What we think affects how we act and feel; what we feel affects what we think and do; what we do affects how we think and feel.
- Extended model: a situation triggers thoughts, which interact bidirectionally with physical reactions, moods/feelings and behaviour; all five elements (situation, thoughts, physical reactions, moods/feelings, behaviour) mutually influence one another.
- Targets of CBT form a cycle: thoughts create feelings, feelings create behaviour, behaviour creates thoughts, and so on. CBT aims to break this vicious cycle of negative thinking and feeling.
Maintaining cycles
Examples of self-perpetuating cycles that CBT targets:
- Fear/avoidance cycle: fear of a situation or object leads to escape/avoidance, which prevents the person learning coping strategies or disconfirming their fear beliefs, so the fear persists.
- Fear/safety-behaviour cycle: fear of a disaster leads to a safety behaviour believed to prevent it; when the disaster does not occur, this is attributed to the safety behaviour rather than to the threat being less likely, so the threat is never disconfirmed and the fear persists.
- Symptom-misinterpretation cycle (panic-type): symptoms of autonomic arousal are misinterpreted as signalling serious physical or mental illness, causing increased anxiety and hence increased symptoms.
- Depression maintenance cycle: depressed mood leads to negative thoughts (activity seen as pointless, unenjoyable or too demanding), which leads to reduced activity and social withdrawal, which leads to loss of positive rewards (pleasure, achievement, social acceptance), which deepens the depressed mood.
- Self-fulfilling prophecy cycle: negative beliefs about other people (e.g. “others won’t like me” or “others will be aggressive”) change the person’s behaviour towards others (withdrawal or hostility); this elicits matching behaviour from others (they stop approaching, or respond with hostility), which appears to confirm the original belief.
- Simplistic advice (e.g. “cheer up”) does not resolve these cycles. A systematic method is needed, such as a daily mood and thought record linking mood, intensity, events and thoughts.
CBT core techniques
Four core, examinable techniques; students must be able to apply one to a case.
Graded exposure
- Directly targets the avoidance that maintains fear, breaking the fear/avoidance cycle.
- Steps: identify what would be hardest, bearable and easiest for the client to do; rate each potential step for expected anxiety on a 0-100 scale; build a hierarchy of multiple steps (e.g. 8-12), chosen collaboratively with the client.
- Sample hierarchy for a dog phobia, fear level 0-100: pictures of dogs (30) - cartoon dog movie (35) - real-life dog children’s movie (40) - Animal Planet dog shows (55) - standing outside a dog park (60) - inside the dog park, dogs brushing past (65) - petting a large dog (70) - giving a large dog a treat (75) - large dog licking the face (80) - petting several dogs in an enclosed space (85) - several large dogs licking the face (90).
- Uses SUDS (Subjective Units of Distress Scale) during exposure: anxiety rises sharply on exposure; escaping at the peak reinforces and maintains the fear; staying instead allows anxiety to decline naturally over time (SUDS score drops), demonstrating that anxiety is not dangerous.
- Combines cognitive and behavioural elements: targets thoughts that increase anxiety, teaches that anxiety is not dangerous, targets the avoidance behaviour maintaining anxiety, and includes homework between sessions.
Exposure and response prevention (ERP)
- Exposure to the feared situation without engaging in the usual safety behaviour, breaking the fear/safety-behaviour cycle.
- Used particularly for OCD: graded exposure to the trigger (e.g. contamination) is combined with prevention of the compulsive response, often practised both in-session and as homework.
- OCD maintenance cycle: relief - obsessions - anxiety - compulsions - back to relief. ERP interrupts this by preventing the compulsion.
Behavioural experiments
- An experiment designed to test an irrational belief or prediction against reality, e.g. “if I stay in a public place it will get so bad I will collapse”, or “if I blush or shake everyone will think I’m an idiot and I’ll have no friends”.
- Client first rates how strongly they believe the prediction, from 0 (not at all) to 100% (absolutely).
- Two types:
- Observational experiment: client gathers evidence by observing a situation without acting directly (e.g. testing “people don’t like me” by observing others’ social interactions).
- Active experiment: client actively does something to test the prediction directly (e.g. deliberately staying in a public place to test “I will collapse”).
- Setting up the experiment: grade the size of the challenge; set a specific time and place; define the predicted outcome and what would count as true or false; rate belief strength (0-100); anticipate problems and plan how to cope; client writes down the actual outcome and whether it matched the prediction.
Evidence for / evidence against
- Identify the unhelpful thought or belief.
- Client writes down the evidence supporting the belief and the evidence against it.
- Client weighs the evidence for and against to arrive at a more balanced thought or belief.
- Worked example: belief “I always fail”; evidence for - “didn’t do well in a recent test”; evidence against - “have done well in most tests”, “even when not doing that well, still passing”; balanced view - “I sometimes fail but overall I am doing OK”.
- Formal tool: a seven-column thought record sheet covering situation/trigger, feelings/emotions (rated 0-100%) and body sensations, unhelpful thoughts/images, facts supporting the unhelpful thought, facts against it, an alternative more realistic/balanced perspective, and the outcome (re-rated emotion).
Summary
- Psychological interventions are indicated for many mental health conditions.
- CBT is an empirically tested treatment method.
- Consider referral for psychological treatment.
Self-test
- Give a brief definition of CBT.
- What are the three broad treatment options for mental disorders, and how does guideline preference generally shift from mild to severe presentations?
- Describe the two defining features of psychotherapy.
- List the four modes of psychotherapy delivery.
- Describe the reciprocal relationships in the cognitive-behavioural triangle of thought, emotion and behaviour.
- Describe the “targets of CBT” cycle and how CBT aims to interrupt it.
- Describe the steps of the fear/avoidance maintaining cycle.
- Distinguish the fear/safety-behaviour cycle from the fear/avoidance cycle.
- Describe the steps of the depression maintenance cycle.
- Describe the self-fulfilling prophecy cycle for negative beliefs about other people.
- Describe the steps involved in setting up graded exposure, including how a hierarchy is built and rated.
- Using SUDS, explain why staying in an anxiety-provoking situation rather than escaping reduces anxiety over time, and what this teaches the client.
- Describe exposure and response prevention and the OCD cycle it targets.
- Distinguish an active behavioural experiment from an observational one, giving an example of each.
- Describe the steps of the evidence for/evidence against technique, using the “I always fail” example.
- Sam is a 21-year-old with a specific phobia of dogs since being bitten at age 12; he avoids beaches and parks and always drives rather than walks to avoid dogs. Which core CBT technique would be used, and briefly describe what it would involve for Sam.
Answers
Reveal answers
- CBT is a short-term psychological treatment for mental disorders that focuses on the links between a person’s thoughts, emotions and behaviour, and the way those links give rise to, or maintain, the disorder.
- Medication, psychological treatment, or a combination of both. Guidelines generally favour psychotherapy alone for mild presentations, shifting towards pharmacotherapy or combined treatment for moderate-severe presentations.
- (1) A relationship between a trained health professional and a person needing help with psychological distress or impaired functioning. (2) Planned, systematic application of specific psychological principles.
- Individual, couple/marital, family, group.
- What we think affects how we act and feel; what we feel affects what we think and do; what we do affects how we think and feel. Each factor reciprocally influences the other two.
- Thoughts create feelings, feelings create behaviour, behaviour creates thoughts, forming a continuous loop; CBT aims to crack this vicious cycle of negative thinking and feeling.
- Fear of a situation/object leads to escape or avoidance, which prevents the person learning coping strategies or disconfirming their fear beliefs, so the fear is unchanged and the cycle repeats.
- In the avoidance cycle the person escapes or avoids the feared situation entirely. In the safety-behaviour cycle the person stays but performs a behaviour believed to prevent a feared disaster; when the disaster doesn’t occur, this is attributed to the safety behaviour rather than to the threat being unlikely, so the fear persists either way.
- Depressed mood leads to negative thoughts (activity seen as pointless, unenjoyable or too demanding), which leads to reduced activity and social withdrawal, which leads to loss of positive rewards (pleasure, achievement, social acceptance), which deepens the depressed mood.
- Negative beliefs about others (e.g. “they won’t like me”) change the person’s behaviour towards others (withdrawal or hostility); this elicits matching behaviour from others (they stop approaching, or respond with hostility), which appears to confirm the original negative belief.
- Identify what would be hardest, bearable and easiest for the client; rate each potential step for expected anxiety on a 0-100 scale; build a hierarchy of multiple steps (e.g. 8-12), chosen collaboratively with the client, then work through it progressively.
- On exposure, anxiety (SUDS) rises sharply; escaping at the peak reinforces and maintains the fear, while staying allows anxiety to decline naturally over time even without escaping. This teaches the client that anxiety is not dangerous and does not need to be escaped.
- Exposure and response prevention exposes the client to the feared situation while preventing the usual safety/compulsive behaviour. For OCD it targets the cycle of relief - obsessions - anxiety - compulsions - relief, by exposing the client to the trigger (e.g. contamination) and preventing the compulsion, often practised in-session and as homework.
- An observational experiment has the client gather evidence by observing a situation without acting (e.g. observing others’ social interactions to test “people don’t like me”). An active experiment has the client actively do something to directly test the prediction (e.g. deliberately staying in a public place to test “I will collapse”).
- Identify the unhelpful belief (“I always fail”); write down evidence for it (“didn’t do well in a recent test”); write down evidence against it (“done well in most tests”, “still passing overall”); weigh the evidence to reach a balanced view (“I sometimes fail but overall I am doing OK”).
- Graded exposure would be the expected technique: build a hierarchy of dog-related situations from least to most anxiety-provoking (e.g. pictures of dogs through to close contact with a large dog), rate each step’s expected anxiety (0-100), choose the steps collaboratively with Sam, and work through them progressively so his anxiety reduces with repeated, non-avoided exposure.